War as a teacher: Experiences of facial reconstruction with anterolateral thigh flap during the Ukrainian war.

[BACKGROUND] The Ukrainian conflict has led to a surge in combat-related facial injuries, characterized by complex soft tissue and bone defects requiring microvascular reconstruction approaches. This study evaluates the efficacy of the anterolateral thigh flap (ALTF) in addressing these challenges.

[METHODS] A retrospective analysis was conducted on 21 patients with warrelated extensive facial bone and soft tissue defects treated at the Head and Neck Surgery Center, Kyiv Regional Hospital, between October 2022 and November 2023. Reconstruction primarily utilized ALTF, with supplementary osseous transplants or endoprostheses where indicated. Variables assessed included ALTF survival rate, complications, distinctive features, overall outcomes. The follow-up period was up to 26 months postoperatively.

[RESULTS] A full-thickness ALTF (skin, fat, fascia) with a median area of 40 cm² (IQR 36-60 cm²) was applied. In most cases (52.3 %), only one vessel perforator was identified. Isolated mucosal defects were observed in 19.0 % of patients, cutaneous defects in 33.3 %, and combined cutaneous and mucosal defects in 47.7 %. All surgeries were performed on a delayed basis, with a median interval of 157 days (IQR 107-132) between injury and reconstruction. The ALTF achieved a 90.5 % success rate, with two flaps failing intraoperatively and replaced by radial forearm free flap (RFFF). Donor site morbidity was minimal. Recipient site complications included postoperative hematoma and wound dehiscence (4 cases each). Preoperative infection was common (47.7 %) but had limited impact on ALTF outcomes.

[CONCLUSION] The ALTF demonstrates high versatility and reliability in reconstructing combat-related facial injuries, offering substantial tissue volume with minimal donor-site morbidity. It provides robust soft tissue coverage, creating favorable conditions for the restoration of underlying bone structures. Despite the high infection rates in military patients, the anatomical variability of the ALTF, and intraoperative challenges such as recipient vessel issues and defect configurations, the ALTF remains a preferred option for complex facial reconstructions in war trauma scenarios.