*Article* **The Free Myocutaneous Tensor Fasciae Latae Flap—A Workhorse Flap for Sternal Defect Reconstruction: A Single-Center Experience**

**Amir Khosrow Bigdeli , Florian Falkner, Benjamin Thomas, Gabriel Hundeshagen, Simon Andreas Mayer , Eva-Maria Risse, Leila Harhaus, Emre Gazyakan , Ulrich Kneser and Christian Andreas Radu \***

> Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany; amir.bigdeli@bgu-ludwigshafen.de (A.K.B.); florian.falkner@bgu-ludwigshafen.de (F.F.); benjamin.thomas@bgu-ludwigshafen.de (B.T.); gabriel.hundeshagen@bgu-ludwigshafen.de (G.H.); simon.mayer@bgu-ludwigshafen.de (S.A.M.); eva-maria.risse@bgu-ludwigshafen.de (E.-M.R.); leila.harhaus@bgu-ludwigshafen.de (L.H.); emre.gazyakan@bgu-ludwigshafen.de (E.G.); ulrich.kneser@bgu-ludwigshafen.de (U.K.)

**\*** Correspondence: christian.radu@bgu-ludwigshafen.de; Tel.: +49-151-2345-6112; Fax: +49-621-6810-2844

**Abstract:** Introduction: Deep sternal wound infections (DSWI) after cardiac surgery pose a significant challenge in reconstructive surgery. In this context, free flaps represent well-established options. The objective of this study was to investigate the clinical outcome after free myocutaneous tensor fasciae latae (TFL) flap reconstruction of sternal defects, with a special focus on surgical complications and donor-site morbidity. Methods: A retrospective chart review focused on patient demographics, operative details, and postoperative complications. Follow-up reexaminations included assessments of the range of motion and muscle strength at the donor-site. Patients completed the Quality of Life 36-item Short Form Health Survey (SF-36) as well as the Lower Extremity Functional Scale (LEFS) questionnaire and evaluated aesthetic and functional outcomes on a 6-point Likert scale. The Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scales (POSAS) were used to rate scar appearance. Results: A total of 46 patients (mean age: 67 ± 11 years) underwent sternal defect reconstruction with free TFL flaps between January 2010 and March 2021. The mean defect size was 194 <sup>±</sup> 43 cm<sup>2</sup> . The mean operation time was 387 ± 120 min with a flap ischemia time of 63 ± 16 min. Acute microvascular complications due to flap pedicle thromboses occurred in three patients (7%). All flaps could be salvaged without complete flap loss. Partial flap loss of the distal TFL portion was observed in three patients (7%). All three patients required additional reconstruction with pedicled or local flaps. Upon follow-up, the range of motion (hip joint extension/flexion (*p* = 0.73), abduction/adduction (*p* = 0.29), and internal/external rotation (*p* = 0.07)) and muscle strength at the donor-sites did not differ from the contralateral sides (*p* = 0.25). Patient assessments of aesthetic and functional outcomes, as well as the median SF-36 (physical component summary (44, range of 33 to 57)) and LEFS (54, range if 35 to 65), showed good results with respect to patient comorbidities. The median VSS (3, range of 2 to 7) and POSAS (24, range of 18 to 34) showed satisfactory scar quality and scar appearance. Conclusion: The free TFL flap is a reliable, effective, and, therefore, valuable option for the reconstruction of extensive sternal defects in critically ill patients suffering from DSWIs. In addition, the TFL flap shows satisfactory functional and aesthetic results at the donor-site.

**Keywords:** sternal defect reconstruction; deep sternal wound infection; DSWI; reconstructive microsurgery; free flap; tensor fasciae latae flap; TFL flap
