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MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH HANOI MEDICAL UNIVERSITY DUONG MANH CHIEN RESEARCH ANATOMICAL CHARACTERISTICS AND CLINICAL APPLICATON OF FREE CHIMERIC ANTEROLATERAL THIGH FLAP Speciality: Orthopedic and Plastic Surgery Code: 62720129 MEDICAL DOCTORAL THESIS HANOI - 2019 The Work has been successfully completed at: HANOI MEDICAL UNIVERSITY Scientific supervisor: Assoc Prof Nguyen Bac Hung Opponent 1: Assoc Prof Le Van Doan Opponent 2: Assoc Prof Vu Quang Vinh Opponent 3: Prof Vu Duc Moi The thesis has been defended at University-level Thesis Evaluation Council held in Hanoi Medical University At, (hour), / /2019 (date) This thesis may be found at: - National Library - Library of Hanoi Medical University BACKGROUND The common causes of large and complex defects for different areas of the body are trauma, burns, tumors The biggest difficulty is finding the right material for each type of damage The Anterolateral Thigh Flap with its own texture, blood supply is considered an appropriate material in complex defect reconstruction Song Y.G has first reported the Anterolateral Thigh (ALT) flap in 1984 to head and neck reconstruction A special using of ALT flap is chimeric flap The chimeric flap is compounded from multiple different flaps, but consists of only a single different tissue form Each of the flaps is usually supplied by different branches from the same source vessel In oder to clarifying the anatomical features of the descending branch of the lateral femoral circumflex artery and the application of ALT flap, we study the subject: “Research anatomical characteristics and clinical application of free chimeric Anterolateral Thigh flap” for purposes of: Describting the anatomical characteristics of the descending branch of the lateral femoral circumflex artery Evaluating the results of using the free chimeric Anterolateral Thigh flap New contributions from the thesis: - Described the anatomical characteristics of the descending of the lateral circumflex femoral artery to creating chimeric anterolateral thigh flap: with 60 thighs, the dissertation given the description of the number, original and size of the descending and the number, size and type of the perforator of the lateral circumflex femoral artery From the results of the research, satisfactory discussions and conclusions were made - In the clinical application, the causes, positions and composition of damages of patients were very various Patients were reconstructed by chimeric flap which have thickness and suitable size The near and far results have proven that using the free chimeric anterolateral thigh flap was effective and reliable New contributions of the dissertation is reflected in the creation of theoretical and practical basis for the construction of the process of using free chimeric anterolateral thigh flap in various complex defects reconstruction Thesis outline: This thesis covers 126 pages, including: preamle (2 pages), the overview (37 pages), materials and method (16 pages), outcomes (33 pages), discussion (36 pages), conclusion (2 pages), recommendation (1 page) It consists of 29 tables, 57 figures There are 101 references, in Vietnamese and English Chapter 1: OVERVIEW 1.1 THE ANATOMICAL CHARACTERISTICS OF THE DESCENDING BRANCH 1.1.1 The anatomical characteristics of the lateral femoral circumflex artery According to the classic anatomy, the lateral femoral circumflex artery is the first branch of profunda femoris artery - a major branch of femoral artery From the origin, the artery goes between the vastus medialis muscle and the pelvic lumbar muscles and divided into branches: ascending, transverse and descending branch 1.1.2 The anatomical characteristics of the descending branch 1.1.2.1 The origin The descending branch usually is one of three branches of the lateral femoral circumflex artery However, there are some anatomical changes, some cases the descending branch is divided from femoral or profunda femoris artery 1.1.2.2 The relation From the origin, the descending branch running along the calibrated line which is connected from anterior inferior iliac spine to lateral patella Descending branch length is about 8-15 cm The outer diameter of artery average mm (2.2-4.0 mm) depeding on the study 1.1.2.3 The branching muscles On the way, the descending branch divides many small, short branches to supply to the rectus femoris, vastus medialis and vastus lateralis muscles The branching muscles are rarely described in anatomical studies 1.1.3 The characteristics of perforators from the descending branch 1.1.3.1 The origin of perforator According to the most of research papers, the perforators in anterior thigh are mainly separated from the descending branch However, some studies also found that the perforators of ascending and transverse branches involves blood supply to the anterior thigh 1.1.3.2 The number of perforator The number of perforator varies according to each report Sung W.C noticed an average of 4.2 perforators originating from the lateral femoral circumflex artery Of which about 68% from the descending branch Kimata Y reported an average of 2,3 perforators from the descending, while Kawai K was 3,8 1.1.3.3 The outer diameter at the origin The outer diameter at the origin of perforator of the descending branch varies according to each report According to Sung W.C the average diameter of perforator is 0,9 mm, proportion of perforator with diameter bigger than 0,5mm accounts for 68,1% Yu P reported 64,3% of cases have diameter greater than 0,5mm 1.1.3.4 The length of perforator The length of perforator and the length of descending branch will determine the length of pedicle of flap The domestic and foreign studies that we have read there are no researches describing this detail 1.1.3.5 The type of perforator According to Song Y.G the perforator supply for ALT flap is septocutaneous perforator, this type accounts for 100% In 1999, Lou S.K studied more about the types of perforator, he classified into four types based on the way to skin of perforator: musculocutaneous (type M), septocutaneous (type S), direct cutaneous (type D) and small perforator 1.1.3.6 Distribution of perforator through the skin In the most of the studied, the perforator through the skin can be found in a circle with a radius of cm at the center of the calibrated line which is connected from anterior inferior iliac spine to lateral patella 1.2 THE PERFORATOR FLAP IN RECONSTRUCTION 1.2.1 A brief history of flaps In the beginning, the flaps were used in random flaps, as the skin was raised without regard to any known blood supply other than to maintain the presence of the subdermal vascular plexus Because of the inherent limited blood supply, random flaps had to be restricted to rigid length to width ratios to assure viability The important mark in the development of flap is when Mc Gregor and Morrgan discovered that some regions of the body had discrete and relatively large subcutaneous vessels that pierced the deep fascia to follow a predictable course Comparatively huge cutaneous flaps, if oriented along the axis of that vascular pathway, consistently maintained complete viability, and appropriately were called axial flaps The concept of musculocutaneous flap was first used in 1906 by Tanzini Pontén deserves credit for reintroducing fasciocutaneous flaps, although he was not quite sure why the inclusion of the deep fascia with his “superflaps” resulted in a longer flap survival length than could be predicted for random flaps of comparable width 1.2.2 Types of perforator flaps are used clinically 1.2.2.1 Conjoined flaps Harii et al first introduced the concept of combined flaps when they described a "combined myocutaneous flaps and microvascular free flap" The purpose of using conjoined flap is to increase the ability to rotate, the extent of reaching while increasing the vitality of the flap In essence, flap is a combination of at least flaps with different anatomical regions, each region has an independent source 1.2.2.2 Chimeric flap The chimeric flap is compounded from multiple different flaps, but consists of only a single different tissue form Koshima I first introduced the concept of chimeric flap Hallock G.G divided the chimeric flap into three subtypes based on the special blood supply of each type In 2015, Kim CS divided the chimeric flap into four subtypes 1.3 CHIMERIC FLAP FROM THE DESCENDING BRANCH 1.3.1 The concepts of the chimeric ALT flap 1.3.1.1 The chimeric perforator flap a The chimeric fasciocutaneous - fasciocutaneous flap The chimeric fasciocutaneous - fasciocutaneous flap with two or more fasciocutaneous flap with each of the flaps is usually supplied by different branches from the same source vessel (usually are descending and transverse branch of the lateral femoral circumflex artery) b The chimeric fasciocutaneous – fascia flap The chimeric fasciocutaneous - fascia flap with fasciocutaneous flap and fascia flap, each of the flaps is usually supplied by different branches from the same source vessel c The chimeric fasciocutaneous – adipose flap The flap is used to recover the skin defects and to fill the tissue defect due to parry - romberg syndrome or sequelae caused by radiotherapy 1.3.1.2 The chimeric perforator - branching muscles flap The chimeric flap with many component flap that this flap is supplied by perforator and the other flap is supplied by branching muscles 1.3.2 The advantages of the chimeric ALT flap 1.3.2.1 Purpose of reconstruction a The covering reconstruction The chimeric ALT flap has many advantages in covering reconstruction, when it is necessary to reconstruct defects in a distant position or need to cover different aspects of an organ b The filled and covering reconstruction The large, complex defects need a special material to filled and covering reconstruction The chimeric perforator - branching muscles flap is used to filled and covering reconstruction c The 3D reconstruction Toal penile reconstruction requires forming the urethra and penis Mehmet M reported a case of reconstructing a penis with a pedicle chimeric ALT flap 1.3.2.2 Microsurgical anastomosis The chimeric flap is compounded from multiple different flaps, but consists of only a single different tissue form Each of the flaps is usually supplied by different branches from the same source vessel Therefore, only by an anastomosis (artery and vein) has enough blood supply for all flaps 1.3.2.3 The donor site Another advantage of ALT flap is that with flexible design, flap can be used to reconstruct larger defects while still being able to primary close the donor site Chapter 2: MATERIALS AND METHOD 2.1 MATERIALS 2.1.1 The anatomical research The Anatomical research was performed on 30 human cadavers with 60 thighs From January 2nd, 2010 to June 1st, 2011 2.1.2 The clinical research Selecting a convenient pattern, all patients suffered from reconstructive surgery by free chimeric ALT flap, 35 patients with 37 free chimeric anterolateral thigh flap From June 2007 to Januany 2016 2.2 METHOD 2.2.1 The anatomical research The method of study is a cross-sectional descriptive study on cadavers 2.2.1.1 The indexes need to collect: The descending branch, the perforator, the branching muscles 2.2.1.2 The tools to collect the data Nikon D90 camera, Surgical kits, marker kits, measuring kits 2.2.1.3 The descending branches were exposed and dataes were collected a The descending branches were exposed: the incision along the medial side of Sartorius muscle from anterior inferior iliac spine to medial patella Tracing the pathway of femoral and profunda femoris arteries to find the descending branches of the lateral femoral circumflex artery The branches of the descending were exposed b Dataes were collected - Qualitative indexes: the origin, relation of descending branches of the lateral femoral circumflex artery, type of the perforator, the direction of the perforator, distribution of perforator through the skin - Quantitative indexes: length of standard line, length of arteries, The outer diameter at the origin 2.2.2 The clinical research The study describes clinical, retrospective and prospective, statistical, synthesized then draw general remarks and conclusions 2.2.2.1 Characteristics of lesions need to be reconstructed by chimeric flap Preoperative evaluation: Time of disease Number of previous surgery, surgery method Causes, location of lesions, size of lesions, injury status: clean damage or infection, good blood supply or not 2.2.2.2 The process of creating the chimeric flap a Surgical planning 11 The branches Number Average/1 descending branch Branching muscles 654 8,9 ± 0,2 Perforator 226 3,1 ± 0,3 Total 880 12,1 ± 0,2 The total number of branches of descending branches was 880, including 654 branching muscles and 226 perforators Average, each descending branch had 12,1 ± 0,2 branches, including 8,9 ± 0,2 8,9 ± 0,2 branching muscles and 3,1 ± 0,3 perforators Table 3.2 Correlation between the branching muscles and perforators in a descending branch (n=73) Branching muscles 0-5 6-10 11-15 >15 Total 4 10 10 17 10 15 0 0 0 2 0 1 Total 17 37 10 73 Perforator 3.1.2.2 The branching muscles There were average 7,9±0,4 branches for a vastus lateralis muscles, of which at most 16 branches There were average 2.0 ± 0.1 12 branches for a vastus lateralis muscles, 0,5±0,1 branches for a vastus medialis muscles 3.1.2.3 The characteristics of perforator of the descending branch - The average number of perforator: On average, there were 3.7 ± 0.3 perforators on a thigh or 3,1 ± 0,3 perforators on a descending branch - Distributing the number of each type of perforator for a descending branch: in 73 descending branches, there were 226 perforators, of which 183 perforators were musculocutaneous (type M), 35 perforators were septocutaneous (type S) and perforators were direct cutaneous (type D) - The average length of perforator: 29,6 ± 1,1 mm with the longest perforator was 105,0 mm and the shortest was 3,0 mm - The diameter of perforator at origin was 1,1 ± 0,03 mm, of which the smallest perforator was 0,4 mm and largest was 3,0 mm - Type of perforator: The M-type accounted for a high percentage (81%), the S and D-type accounted for a low percentage (19%) 3.2 CLINICAL RESEARCH RESULTS 3.2.1 The characteristics of damages 3.2.1.1 The causes of damages Table 3.3 The causes of damages (n Causes Number Anophthalmia Congenital Microtia disease Cleft face gender reassignment Due to injury = 37) Total Ratio (%) 13,5 10 27,1 13 Soft tissue Sequelae of defects inflammation Burn Due to injury snakebite Benign tumors Malignant tumors Ulcers caused by radiotherapy Scars Tumors Total 12 32,4 16,2 10,8 37 100 The most common cause was scar sequelae (12 cases) Next was the soft tissue defects with 10 cases, tumors were cases, congenital disease were and ulcers caused by radiotherapy were cases 3.2.1.2 The position of damages was reconstructed A total 78 the position of damages was reconstructed, head and neck were the most with 46 positions (59%), followed by upper limbs with 19 positions (24.4%), followed by lower limbs with 10 positions (12.8%), penis with positions (2.5%) and the chest with position (1.3%) 3.2.1.3 The tissue is damaged Table 3.4 The tissue is damaged Skin, fat Skin, fat, and muscles and muscles bone 11 11 15 37 29,7 29,7 40,6 100 The tissue is Skin and damaged fat Number of damages Ratio (%) Total 14 The damaged tissue composition was diverse, in which fat lesions had 11 cases, skin lesions with muscle tendons had 11 cases and skin, fat, muscles and bone damage had 15 cases 3.2.2 The characteristics of using flaps 3.2.2.1 Characteristics of ALT flaps before dividing into chimeric flaps Table 3.5 Number of microsurgical anastomosis Type of anastomosis Number of Artery Vein 1 Number of flaps 37 32 Total of anastomosis 37 Ratio (%) 100 anastomosis 71 10,8 86,5 2,7 - Number of perforators for flap: there were 80 perforators (average 2,2 perforators for a flap) Of which, 31 flaps had perforators and flaps had perforators - Size of flaps: The average length of flap was 203 ± 10 mm The average width of the flap was 90 ± mm - Thickness of flaps: flaps were not thinned, flaps were primary thinned and 18 flaps were thinned with microsurgical technique The average thickness of flaps before thinned was 17.1 ± mm and after thinned was 7.6 ± mm - Composition of flaps: the adipocutaneous flap had 20 (54,1%), fasciocutaneous flap had 11 (29,7%) and musculocutaneous flap had (16,2%) 3.2.2.2 Characteristics of ALT flaps after dividing into chimeric flaps 15 37 ALT flaps after dividing into chimeric flaps, there were 75 single flaps, including 36 chimeric flaps had single flaps and chimeric flaps had single flaps Table 3.6 The average length of perforator Perforator Number The average length (mm) Perforator 37 47,2 ± 1,8 Perforator 37 53,2 ± 2,7 Perforator 46,6 ± 6,7 Total 80 50,0 ± 1,6 - The distance between the origin of perorator and was average 48.5 ± 3.8 mm, the distance between the origin of perorator and was 36,1 ± 4,4 mm Table 3.7 Type of perforator Perforator Type of perforator Total M S D Perforator 29 (78,4%) (21,6%) (0%) 37 Perforator 31 (83,8%) (16,2%) (0%) 37 Perforator (100%) (0%) (0%) Total 66 14 (0%) 80 Ratio (%) 82,5 17,5 100 - Composition of single flaps: the adipocutaneous flap had 47, fasciocutaneous flap had 20, muscle flap had 4, musculocutaneous flap had and fascial flap had - Size of single flaps: 37 number single flaps, the average length of single flaps was 125 ± mm, the average width of single flaps was 16 86 ± mm 33 number two single flap 2, the average length was 88 ± mm and the average width was 63 ± mm 3.2.2.3 The characteristics of reconstruction 17 chimeric ALT flaps (45,9%) were used to covering reconstruction chimeric flaps were used to reconstruct the organ, chimeric flap was used to filled reconstruction and 17 flaps were used to combined reconstruction Table 3.8 Reconstruction related to the location of the damages Direction Same opposite direction direction Head and neck 17 21 Upper limb 10 Lower limb Penis 1 Total 28 37 Location Total 3.2.2.4 Vessels of source receiver Table 3.9 Arteries of source receiver (n=37) Vessels of source receiver Arteries Number Total Location Head and neck Upper limb Facial a 18 Superficial temporal a Radial a Radial a in anatomical 21 10 snuffbox Lower limb Posterior tibial a Anterior tibial a 17 Vessels of source receiver Arteries Number Total Location Penis Deep inferior epigastric a Total 37 3.2.3 Postoperative general results 3.2.3.1 The early outcomes Table 3.10 The survival of flaps The survival of Total Partial Total flaps survival survival necrosis 30 37 81,1 8,1 10,8 100 Number of chimeric flaps Ratio (%) Total In 37 chimeric ALT flaps were used, 30 flaps were total survival (81,1%), flaps were partial survival (8,1%) and were total necrosis (10,8%) Table 3.11 The general results (n=37) Results Excellent Good Average Weak Total Donor site 28 1 37 Receipt site 23 37 In the donor site, the excellent result was 28 cases, good result was cases, average result was case and weak result was case In the receipt site, the excellent result was 23 cases, good result was cases, average result was cases and weak result was cases 18 3.2.3.2 The distant outcomes We reexamined months after surgery for 35 patients (with 37 flaps) Bảng 3.13 The distant outcomes Results Excellent Good Average Weak Total Donor site 30 37 Receipt site 26 5 37 In the receipt site, the excellent result was 26 cases, good result was cases, average result was case and weak result was cases In the donor site, the excellent result was 30 cases, good result was cases and average result was case Chapter 4: DISCUSSION 4.1 CHARACTERISTICS OF THE DESCENDING BRANCH 4.1.1 The anatomical characteristics of the descending branch In 73 descending branches, there were 55 descending branches with the origin from the lateral femoral circumflex artery (75,3%), branches (8,2%) from femoral and 12 branches (16,5%) from profunda femoris artery 4.1.2 The branching characteristics of the descending branch 4.1.2.1 The characteristics of the branching muscles The number branches for a vastus lateralis muscles was the most with the average 7.9 ± 0.4 branches for muscle There was an average of 2.0 ± 0.1 branches for a vastus lateralis muscle and 0,5±0,1 branches for a vastus medialis muscle According to many 19 references, we found that the authors did not describe the characteristics of the branching muscles 4.1.2.2 The characteristics of perforators In 60 specimens, there were 226 perforators from descending branches, average of 3.7 ± 0.3 perforators on a thigh This result is similar to the other authors such as Kimata Y the average 2.3 perforators on a thigh, Kawai K is 3.8 or Tansat T is 2.2 4.1.2.3 Correlation between the branching muscles and perforators In 73 descending branches, there were 57 descending branches (78%) with two or more perforators Therefore, with about 78% of cases we can create the chimeric fasciocutaneous - fasciocutaneous flap Considering the case had perforator and branching muscles, we had 64/73 (87,7%) descending branches So there are about 91.8% of cases we can create the chimeric perforator - branching muscles flap 4.2 CHARACTERISTICS OF USING THE CHIMERIC ALT FLAP 4.2.1 The advantages of the free chimeric ALT flap 4.2.1.1 Lesions were reconstruction differently in many locations and due to many different causes Our research, the most common cause was sequelae scarring (12 cases) Next, soft tissue defects had 10 cases, cause of tumors with cases, followed by congenital malformations with cases and finally, ulcerative sequelae of radiotherapy with cases Based on location of lesions, the most common neck and head area with 46 positions including lesions in lips, nose, cheeks, optic, midface, ears, neck Next was the upper limb with 19 positions including hands, arms and forearms Lower limb with 10 positions, finally the penis and the 20 chest had a lesion A total of 78 lesions were reconstruction by 37 free chimeric ALT flaps 4.2.1.2 Size of flaps modified depending on size of the lesions The average length of flap was 20.3 ± cm with the smallest was cm and the largest was 37 cm The average width of the flap was ± 0.4 cm, the smallest was cm and the largest was 15 cm 4.2.1.3 The composition of flap is diverse In principle, the defects are reconstructed with materials of similar tissue composition On the other hand, with complex defects, reconstruction is not only recover or filling but also 3D reconstruction Therefore, it is necessary to have a material with diverse tissue components and can be divided into different parts that the result is the best The chimeric ALT flap has many characteristics to achieve the above requirements 4.2.1.4 Number of microsurgical anastomosis In total, there were 37 aterial anastomosises, 71 varicose anastomosises Thus, with 78 lesions in 78 different positions, when using free flaps, at least 78 flaps are required with 78 aterial anastomosises and from 78 to 156 varicose anastomosises However, when using the chimeric flaps, we only have to use 37 flaps with a smaller number of microsurgical anastomosis (37 aterial anastomosises and 71 varicose anastomosises.) 4.2.2 The characteristics of using flaps 4.2.2.1 The chimeric ALT flap in covering reconstruction Our study had 17 chimeric ALT flaps (45.9%) used for the covering reconstruction at skin or mucosa defects We used the chimeric ALT flaps for the covering reconstruction in some cases: Firstly, lesions occur in many locations far away from each other, in which each flap 21 will reconstruct for a lesion Second, the full thickness defects in the cheek Thirdly, defects are large in size, using a normal flap will have to be flap with large size, then can not close directly to the donor site Finally, we used chimeric ALT flap for long defects 4.2.2.2 The chimeric ALT flap in filled reconstruction In clinical practice, sometime surface defects and dead spaces are not in the same position, we cannot be reconstructed by a flap In cases, a chimeric ALT flap with a flap is used to fill the dead zone, while the other flap is used to cover 4.2.2.3 The chimeric ALT flap in 3D reconstruction Our research has 19 chimeric ALT flaps in 3D reconstruction Including 16 flaps were used for head and neck, flaps for upper limd and flap for penis 4.2.3 Postoperative general results 4.2.3.1 The survival of flaps The early outcomes, in 37 chimeric ALT flaps were used, 30 flaps were total survival (81,1%), flaps were partial survival (8,1%) and were total necrosis (10,8%) In 75 single flaps, 64 flaps were total survival (85,4%), single flap was partial survival án 10 single flaps were total necrosis 4.2.3.2 The donor site 29 cases were primary healing, cases were second healing and case were severe complications, muscles in thigh was partial necrotic The cause was a larger defect but we still try to close primary 4.2.3.3 Complications and causes of failure chimeric ALT flaps were necrosis, in which partial necrosis had flaps and complete necrosis had flaps We found that, with flaps 22 were completely necrosis, the cause of hematoma under the flap had cases and the cause of intraoperative thrombosis had caes 4.2.3.4 The distant outcomes Evaluate the results after months, at the receipt site we assessed based on the color, thickness of flaps, contour, hair on flaps… which gived levels of excellent, good, average and weak results In the receipt site, the excellent result was 26 cases, good result was cases, average result was case and weak result was cases In the donor site, the excellent result was 30 cases, good result was cases and average result was case CONCLUSION CHARACTERISTICS OF THE DESCENDING BRANCH 1.1 Descending branch - Number: 73 descending branches, of which 47 thighs had and 13 thighs had descending branches - Origin: 55 branches from the lateral femoral circumflex a., branches from femoral and 12 branches from profunda femoris a - The outer diameter: in case there are one is an average 2,9 ± 0,1mm in case there are two is an average 2,5 ± 0.2mm - The length: outer descending branches was 262,7 ± 4,3mm, inner descending branches was 196,9± 17,5mm - The branches: 880 branches including 654 branching muscles and 226 perforators 1.2 Perforators - Number: there were 226 perforators, average 3,1 ± 0,3 perforators on a descending branch - The average length of perforator: 29,6 ± 1,1 mm with the longest perforator was 105,0 mm and the shortest was 3,0 mm 23 - Type of perforator: The M-type accounted for a high percentage (81%), the S and D-type accounted for a low percentage (19%) 1.3 The branching muscles - There were 654 branching muscles Average each descending branch had 8,9 ± 0,2 branching muscles - 7,9±0,4 branches for a vastus lateralis m., 2.0 ± 0.1 branches for a vastus lateralis m., 0,5±0,1 branches for a vastus medialis m CLINICAL RESULTS 2.1 The characteristics of damages - The causes of damages: scar sequelae (12 cases), soft tissue defects (10 cases), tumors (6 cases), congenital disease (5 cases) and ulcers caused by radiotherapy (4 cases) - The position of damages: head and neck with 46 positions, upper limbs with 19, lower limbs with 10, penis with 2, chest with - The tissue is damaged: fat lesions had 11 cases, skin lesions with muscle, tendons had 11 cases, composite lesions had 15 cases 2.2 The characteristics of using flaps 2.2.1 The characteristics of flaps before dividing into chimeric - Size of flaps: The average length of flap was 203 ± 10 mm The average width of the flap was 90 ± mm - Thickness of flaps: before thinned was 17.1 ± mm and after thinned was 7.6 ± mm - Composition of flaps: adipocutaneous had 20 (54,1%), fasciocutaneous had 11 and musculocutaneous had 2.2.2 The characteristics of flaps after dividing into chimeric - Average length of single pedical was 106 ± mm and single pedical was 161 ± mm - Size of single flaps: average length was105 ± mm and average width was 72 ± mm 24 2.3 Postoperative general results - In the receipt site: 23 cases were excellent, were good, were average and were weak The distant outcomes, 26 were excellent, were good, was average and were weak - In the donor site: 28 cases were excellent, were good, was average and was weak The distant outcomes, 30 were excellent, were good and was average LIST OF ANNOUNCED RESEARCH PROJECTS RELATED TO THESIS TOPIC Duong Manh Chien, Tran Dang Khoa (2016) Anantomy of the descending branch of the lateral femoral circumflex and application in reconstruction The Vietnamese Journal of Medical Resesrch (449), Dec -2016, Page.2025 Duong Manh Chien, Tran Thiet Son (2016) characteristics of a chimeric anterolateral thigh free for reconstruction of the head and neck defects Vietnamese Journal of Medical Resesrch (449), -2016, Page.114-122 Duong Manh Chien, Tran Thiet Son (2016) The characteristics of a chimeric anterolateral thigh free flap for reconstruction of the hand defects The Vietnamese Journal of Medical Resesrch (449), Dec -2016, Page.154161 Duong Manh Chien, Tran Thiet Son (2016) The chimeric anterolateral thigh free flap for reconstruction of hand scar sequela snakebite The Vietnamese Journal of Medical Resesrch (449), Dec -2016, Page.203-208 The flap The Dec ... flaps 1.3.2.3 The donor site Another advantage of ALT flap is that with flexible design, flap can be used to reconstruct larger defects while still being able to primary close the donor site Chapter... source of the artery received, how to close the donor site Planning surgical steps b Prepare patients before surgery: At the place to receive flap and donor site c Surgical procedure Team 1: Harvesting... Combined with the characteristics of demanges, the chimeric ALT flap were designed - Cutting the pedicle: Cutting the pedicle and transferred to the receiving place Team 2: Prepare the receiving

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