[Clinical efficacy of ALTF combined with "Y"-shaped great saphenous vein graft in repairing large soft tissue defects in the proximal-middle segment of the lower leg].

Objective: To explore the clinical efficacy of using the anterolateral thigh flap (ALTF) combined with "Y"-shaped great saphenous vein graft in repairing large soft tissue defects in the proximal-middle segment of the lower leg. Methods: This study was a retrospective case series study. From January 2019 to December 2023, 8 patients with large soft tissue defects in the proximal-middle segment of the lower leg meeting the inclusion criteria were admitted to the Department of Hand & Foot and Reconstructive Microsurgery of Shandong Provincial Hospital Affiliated to Shandong First Medical University, including 7 males and 1 female, aged 15 to 63 years. After the wounds were cleaned and the infection was controlled, the areas of soft tissue defects in the lower leg ranged from 18 cm×7 cm to 30 cm×14 cm. The ALTF combined with "Y"-shaped great saphenous vein graft was conducted to repair the soft tissue defects in the lower leg. The flap harvest areas were 19 cm×8 cm to 31 cm×15 cm. Intraoperatively, the bifurcated ends of the "Y"-shaped great saphenous vein were end-to-end anastomosed with the descending genicular artery and the medial femoral muscle branch (MFMB), respectively, and the main trunk end was end-to-end anastomosed with the descending branch of lateral femoral circumflex artery (LFCA-DB), constructing a "dual-in, single-out" venous bridging mode. The dominant concomitant vein of LFCA-DB was end-to-end anastomosed with the recipient great saphenous vein. If there was no suitable vein in the recipient area of the lower leg for anastomosis with the dominant concomitant vein of LFCA-DB, a segment of the great saphenous vein from the contralateral lower leg was harvested and bridged to the dominant concomitant vein of LFCA-DB, and then end-to-end anastomosed with the above-knee great saphenous vein. The flap donor site wounds were directly sutured in 3 cases, and repaired with full-thickness skin grafts from the ipsilateral inguinal region in 5 cases. The length of the flap pedicle vessels and the length of the defect between the flap pedicle vessels and the planned anastomotic descending genicular artery and MFMB were recorded. Postoperatively, the flap survival and the wound healing in the donor sites were observed. During follow-up, the appearance, texture, and sensory recovery of the flaps, the recovery of flap donor sites, and the limb swelling in the vein donor sites were observed. At the last follow-up, the 5-point Likert scale was used to investigate the satisfaction of patients with the treatment effects in the flap recipient and donor sites. Results: The lengths of the flap pedicle vessels of patients were 12 to 17 cm, with an average of 14.1 cm. The lengths of the defects between the flap pedicle vessels and the planned anastomotic descending genicular artery and MFMB were 9 to 16 cm, with an average of 12.3 cm. Postoperatively, all flaps survived completely, without vascular crisis; all flap donor site wounds healed well. During follow-up of 12 to 40 months, the flaps of 6 patients showed no bulkiness; two flaps developed local bulkiness due to compression during the subsequent tibial bone transport treatment, of which one case improved after surgical debulking, and one case received no modification treatment. The flaps were soft in texture, with moderate tension and no ulcer, and all regained protective sensation. The flap donor sites all recovered well. The direct suture areas left slight linear scars, the skin grafted areas left slight scars, and the limbs in the vein donor sites showed no swelling. At the last follow-up, the satisfaction scores of patients with the treatment effects in the recipient and donor sites were all 4 and 5. Conclusions: The application of ALTF combined with "Y"-shaped great saphenous vein graft anastomosed to the descending genicular artery and MFMB to repair large soft tissue defects in the proximal-middle segment of the lower leg can effectively achieve the caliber physiological matching of the donor and recipient vessels, ensure the blood supply of the large-area flaps through dual blood supply, and avoid the periwound inflammation to reduce the risk of vascular crisis. The patients are satisfied with the treatment effect of the donor and recipient sites.