The Evolutionary Trajectory of the ALT Flap in Nasal Reconstruction: A Literature Review and Clinical Experience

Abstract

Introduction

Reconstruction of complex nasal defects involves restoring external skin, internal lining, and support within a 3D framework. While the forehead flap is considered the gold standard, free tissue transfer is used when local tissues are unavailable. Historically, the radial forearm flap (RFF) was favored for its thinness and pliability. The anterolateral thigh (ALT) flap, once limited by bulkiness, has been refined. This study examines the evolution and current role of the ALT flap in the nasal reconstruction algorithm.

Methods

A sequence of patients with nasal defects received reconstruction with a free ALT flap. Additionally, a targeted literature review was performed to explore recent advances in perforator dissection, flap thinning, and chimeric design relevant to nasal reconstruction. The study assessed flap configuration, thinning techniques, structural repair, complications, and long-term results.

Results

Eighteen flaps were performed: twelve for nasal reconstruction and six for adjacent facial subunits. Five patients required total nasal reconstruction. The mean flap thickness decreased from 24.6 ± 5.5 mm to 5.7 ± 2.4 mm after combined primary and microdissection thinning, a 77% reduction. Chimeric and multi-paddle configurations enabled simultaneous restoration of skin, lining, and composite defects. Flaps were viable with no partial necrosis. Long-term follow-up over 1 to 8 years demonstrated stable airway function and maintained satisfactory contour.

Conclusions

The ALT flap has evolved from a secondary reconstructive option to a refined material for complex nasal defects. Advances in perforator-based thinning and hybrid designs have expanded its use, making it a viable alternative to traditional forearm reconstruction in some patients.

Keywords

ALT flap nasal reconstruction free flap rhinoplasty

Introduction

Partial and total nasal defects caused by trauma, oncologic resection, or burns require reconstructive strategies tailored to defect size, tissue composition, and the involved aesthetic subunit. The paramedian forehead flap (FF) remains the gold standard for complex nasal reconstruction because of its reliable vascularity and favorable tissue match. However, it may not be feasible when the donor site is compromised or insufficient, necessitating free tissue transfer.^1,2

The radial forearm flap (RFF) has been widely used for complex nasal defects due to its thin, pliable skin and dependable vascular pedicle. Nevertheless, it requires the sacrifice of the radial artery and may be associated with donor-site morbidity. In addition, it may provide insufficient soft-tissue volume when defects extend to adjacent facial subunits.^1,3-5

Since its introduction as a perforator flap, the anterolateral thigh (ALT) flap has become a workhorse in reconstructive microsurgery. Its application in nasal reconstruction was initially limited by excessive thickness and challenges in achieving refined contouring.^1,6 Recent advances in primary and microdissected thinning techniques have broadened their applications, allowing for single-stage reconstruction of specific nasal defects in suitable patients. However, the indications, technical developments, and outcomes of the ALT flap in nasal reconstruction have not been thoroughly examined. This study reviews the evolution of the ALT flap in nasal reconstruction and shares our clinical experience with thinned ALT flaps. Our goal is to highlight technical improvements and define their role in reconstructing complex three-dimensional nasal structures within current reconstructive practices.

Materials and Methods

Between July 2007 and September 2021, ten consecutive patients with nasal defects underwent reconstruction using a free ALT flap. To ensure academic transparency, it is declared that two patients within this 10-patient cohort were previously included in our focused technical case reports.^7,8 However, their inclusion in the current study is strictly for the purpose of presenting a comprehensive overview of our long-term clinical experience and structural intervention techniques. The data analysis, categorization of flap evolution phases, and the accompanying discussion are entirely separate and decoupled from the specific discussions and parameters presented in those previous reports The cohort consisted of six males and four females, with a mean age of 42.7 years (range, 24–67 years). All male patients reported a history of smoking. Etiologies included extensive facial burn scars with nasal defects in four patients, radical tumor resection in four patients (comprised of two basal cell carcinomas and two squamous cell carcinomas), crush injuries to the face in one patient, and radiation-induced nasal defects in one patient. Three patients had nasal skin defects, while seven had full-thickness nasal defects (two with partial and five with total defects). Eight patients showed involvement of adjacent facial subunits, including the forehead, cheek, or lips. The mean cutaneous defect size was 53.8 cm² (range 30–80 cm²). Baseline characteristics of all patients are summarized in Table 1. This surgical case series has been executed and is reported in strict adherence to the Preferred Reporting Of Case Series in Surgery (PROCESS) 2023 guidelines. All relevant checklist elements regarding operational contexts, chronological execution, and sequential clinical settings have been integrated.

Table 1.

Surgical Characteristics of Patients Undergoing Nasal Reconstruction With the ALT Flap

Case	Age/sex	Etiology	Nasal defect	Flap type	Flap size (cm)	Pedicle size (cm)	Flap thickness before/after	Framwork	Lining
1	37/M	Post -radiation	Nasal full-thickness coverage	Chimeric	10x8	14	25/7	Costal Cartilage	ALT flap
1	37/M	Post -radiation	Nasal full-thickness coverage	Thinned	8x6	14	25	Costal Cartilage	ALT flap
2	28/F	Burnscar	Nasal coverage	Single	12 x 8	12	30/6	Alloplastic implant	Local flap
2	28/F	Burnscar	Nasal coverage	Thinned	12 x 8	12	30/6	Alloplastic implant	Local flap
3	24/F	Burnscar	Nasal coverage	Thinned	13x12	15	15/4	Costal Cartilage	ALT flap
4	66/M	BCC	Nasal coverage	Chimeric	9x5	12	25/8	-	-
4	66/M	BCC	Nasal coverage	Thinned	9x5	12	25/8	-	-
5	60/F	BCC	Nasal coverage	Chimeric	12x10	12	28/4	Alloplastic implant	ALT flap
5	60/F	BCC	Nasal coverage	Thinned	8 x 4	12	28/5	Alloplastic implant	ALT flap
6	34/F	Burnscar	Total nose	Chimeric	13 x 8	16	30/4	Alloplastic implant	Local flaps
6	34/F	Burnscar	Total nose	Thinned	13 x 8	16	30/4	Alloplastic implant	Local flaps
7	32/M	Burnscar	Total nose	Chimeric	12 x 8	14	30/4	Alloplastic implant	Local flaps
7	32/M	Burnscar	Total nose	Thinned	12 x 8	14	30/4	Alloplastic implant	Local flaps
8	23/M	Trauma	Total nose	Expanded	12x10	14	24/12	Iliac crest bone	ALT flap
8	23/M	Trauma	Total nose	Thinned	12x10	14	24/12	Costal Cartilage	ALT flap
9	67/M	SCC	Total nose.	Chimeric	12 x 8	15	20/4	Costal cartilage	ALT flap
9	67/M	SCC	Total nose.	Thinned	12 x 8	15	20/4	Costal cartilage	ALT flap
10	60/M	SCC	Total nose,	Chimeric	14x12	15	17/5	Costal Cartilage	ALT flap
10	60/M	SCC	Total nose,	Thinned	14x12	15	17/5	Costal Cartilage	ALT flap

M: male; F: female; BCC: basal cell carcinoma. SCC: squamous cell carcinoma.

Surgical Technique

All ALT flaps were harvested using a standardized approach for nasal reconstruction. Preoperative perforators were located with a handheld Doppler device, and the skin paddle was designed according to the size and configuration of the nasal defect. Dissection began along the flap’s medial border, extending to the subfascial plane to identify the descending branch of the lateral circumflex femoral artery (LCFA) and its perforators. These perforators were dissected retrogradely to their origin. Depending on perforator availability and reconstructive needs, either a single-paddle flap or a bipaddled/tripaddled chimeric flap was raised. If fewer than two suitable perforators from the descending branch were available, an additional perforator from the oblique or transverse branch of the LCFA was included and connected to the distal descending branch to form a chimeric configuration.

Prior to pedicle division, the flap was thinned using a combination of primary thinning and microdissection techniques. Primary thinning involved removing adipose tissue between the superficial fascia and fascia lata with blunt scissors while preserving the subdermal vascular network and a protective fascial cuff around the perforator. Thinning was done from the periphery inward toward the perforator, reducing flap thickness to approximately 8–12 mm.

Next, microdissection thinning under a microscope was used to excise deep fat lobules within the superficial fat layer while preserving perforator branches. This process reduced the flap thickness further to about 3–7 mm, ideal for detailed nasal shaping. Flap perfusion was verified before dividing and transferring the pedicle.

Microvascular connections were typically made end-to-end or side-to-end, mainly to the facial artery and veins. The flap was inset to reconstruct the nasal dorsum and subunits. When needed, local flaps provided mucosal lining, and structural support was supplied with costal cartilage or silicone implants.

Donor sites were closed primarily when possible or covered with split-thickness skin grafts. Postoperative monitoring was performed for five days to detect any vascular issues. Long-term aesthetic and functional outcomes were assessed at least 12 months postoperatively by a collaborative consensus panel including the primary operating surgeon, an independent plastic surgeon observer, and subjective patient self-reports satisfaction. Additional debulking procedures were performed as needed to improve contour and aesthetics.

Results

Eighteen flaps were performed across ten patients, including twelve for nasal reconstruction and six for adjacent facial subunits. Among the nasal reconstructions, five were total defects, four partial, and one full-thickness. Eight flaps were designed as single-perforator, while two were hybrid configurations. The average skin paddle size was 11.1 × 8.2 cm (range, 8–13 × 4–12 cm), with an average pedicle length of 13.9 ± 1.4 cm (range, 12–16 cm). The initial flap thickness averaged 24.6 ± 5.5 mm (range, 15–30 mm). Ten flaps underwent thinning, reducing the thickness to an average of 5.7 ± 2.4 mm (range, 4–12 mm), or about 77% reduction. Internal lining was reconstructed using a microdissected, thinned ALT flap in six patients and local flaps in two. Structural support involved costal cartilage grafts (n=5) or silicone implants (n=4). All flaps were anastomosed end-to-end to facial vessels. Complete flap survival was achieved in all cases, with no partial or total necrosis. Primary healing occurred at both donor and recipient sites without major complications. The donor site was primarily closed in seven cases and required split-thickness skin grafts in three. Three patients needed secondary refinements at 12 months to improve contour. After 1–8 years, airway patency remained stable, and aesthetic outcomes were satisfactory. The surgical details of nasal defect reconstruction with the ALT flap are summarized in Table 2.

Table 2.

Summary of Surgical Subunits, Flap Configurations, and Reconstructive Techniques

Procedure	Nasal defect	Skin defect (n)	Partial defect (n)	Total defect (n)
Coverage	Expanded flap			1
Coverage	Thinned flap	4	1	4
Lining	Local flap		2
Lining	Thinned flap		1	5
Frame	Silicone		1
Frame	Costal cartilage			5
Secondary thinning				2

Discussion

Free Flaps in Nasal Reconstruction

The forehead flap remains the gold standard for nasal reconstruction because of its technical simplicity and superior tissue match. However, it is not feasible in patients with extensive forehead scarring or prior skin grafting, where the donor site is compromised. In such circumstances, free tissue transfer becomes the preferred alternative.^9,10 Among these options, the RFF has been widely adopted due to its thin, pliable properties and its versatility in three-dimensional nasal reconstruction. When harvested purely as a fascial flap, it lacks an epidermal layer, which prevents crusting and irritation inside the nose, does not contract, and can be easily grafted with nasal mucosa.¹¹ The RFF can be used in either single- or multi-stage total nasal reconstruction.^10,12-15 Nevertheless, its use entails the sacrifice of a major artery to the hand and may result in significant donor-site morbidity. Furthermore, in cases involving extensive composite defects across multiple facial subunits, the RFF may be limited in its ability to provide sufficient tissue volume while simultaneously restoring complex three-dimensional structure. Besides RFF, the free temporoparietal Fascial Flap (TPFF) also provides a role in nasal reconstruction. It is an ultra-thin, highly vascularized flap and has been highlighted for complex partial or total nasal reconstructions to provide internal lining, cover the structural cartilage framework, and support outer skin grafts. However, relying on skin grafts over the fascia can result in a color mismatch with the natural nasal skin, require complex microsurgery, and sometimes necessitate multistage prelamination procedures.^9,16,17 Some authors mention additional free flaps, including the ulnar forearm flap, the first dorsal metacarpal artery flap, the temporal artery auricular flap, and the ear helix free flap. However, these have limited uses and are mainly applied to small defects.^16,18-20

The Role of the ALT Flap in Nasal Reconstruction

Since Song et al. first described it, the free ALT flap has become a dependable option for repairing defects throughout the body, including the head and neck.²¹ Traditionally, it hasn’t been considered a top choice for total nasal reconstruction due to its bulkiness and limited similarity to facial skin. However, recent advances in perforator dissection and flap-thinning techniques have broadened its use in nasal reconstruction.^6-8,22,23 Methods such as primary thinning and microdissection have markedly reduced flap thickness while maintaining vascular reliability, enabling more accurate contouring of nasal subunits. For suitable patients, these innovations have enabled single-stage reconstruction of subtotal or total nasal defects, yielding satisfactory aesthetic and functional results.^8,24,25 As a result, the ALT flap’s role has shifted from a secondary option to a versatile platform capable of addressing complex three-dimensional nasal defects.

The development of microvascular techniques has expanded reconstructive options for complex nasal defects, with the ALT flap becoming increasingly recognized as a versatile staple. Early pioneers such as Koshima et al. introduced the concept of combined chimeric tissue transfer based on the lateral circumflex femoral system, enabling independent harvesting of skin, fascia, and muscle to repair three-dimensional facial defects.²⁶ Subsequently, a major topic in the literature concerns choosing between the RFF flap and alternative options, such as ALT. Valentini et al. described the ALT flap as a reliable alternative to the RFF, noting that although the RFF is traditionally preferred for its thinness, the ALT provides comparable reliability with better donor-site aesthetics in head and neck reconstruction.²⁴ The ALT donor site offers flexibility for various design modifications tailored to specific reconstructive needs. Studies by Seth et al. and Aliotta et al. reported good outcomes using the free fascia lata component for isolated lining and columella defects, while Revenaugh et al. described an adipofascial variant for mucosal restoration.^23,27,28 A review by Ramji et al. found that the RFF remains the most common flap for nasal lining (50.8%), but the ALT flap (16.9%) is more often selected when a larger surface area or longer pedicle is needed, especially in cases where forearm donor-site morbidity is a concern.²⁹ Similarly, Livaoglu et al. suggested that the ALT donor site may have lower functional and aesthetic morbidity compared to the RFF.²² Recent research has focused on reducing the bulk associated with the ALT flap. Kim et al. and Pinto et al. supported microsurgical approaches for total rhinectomy reconstruction, with Pinto directly comparing ALT and RFF for total nasal defects to improve aesthetic subunit restoration.^1,10 Technical improvements, such as super-thin and pre-laminated modifications described by Bali et al. and Yen et al., have broadened the use of the ALT flap in nasal reconstruction.^2,3,30 Hsu et al. also demonstrated the use of chimeric skin bipaddle ALT flaps for simultaneous nasal airway and maxillary reconstruction, showing the donor site’s ability to provide multiple tissue components when needed.⁵ Historically, the bulkiness of the ALT flap limited its use in nasal reconstruction. Research on ALT flaps in nasal reconstruction is summarized in Table 3.

Table 3.

Literature on ALT Flaps in Nasal Reconstruction

Year	Author	Method	Study type	Flap type	Reconstructive site	n
1997	Koshima²⁵	Introduced the use of chimeric ALT flaps for reconstructing complex facial and nasal defects	Case Series	Chimeric ALT Flap	Complex Facial/Nasal	3
2008	Valentini²³	Conducted a clinical study evaluating the free ALT flap as a viable alternative or replacement for the radial forearm flap in head, neck, and nasal reconstruction	Clinical Study	Free ALT Flap	Head and Neck/Nasal	10
2009	Livaoglu¹⁹	A case series on the reconstruction of full-thickness nasal defects using free ALT flaps	Case Series	Free ALT Flap	Full-thickness Nasal	6
2013	Seth²⁶	Focused on the application of the free fascia lata (ALT) flap specifically for repairing complex nasal lining defects	Case Series	Free Fascia Lata (ALT)	Nasal Lining	5
2014	Revenaugh²⁰	The application of the free fascia lata (ALT) flap specifically for repairing complex nasal lining defects	Retrospective	Free Fascia Lata (ALT)	Oral and Nasal Mucosa	11
2016	Lawson⁶	The versatility of chimeric ALT-free flaps in complex head and neck reconstruction	Retrospective	Chimeric ALT Flap	Complex Head & Neck	24
2017	Kim¹	A review of the various microvascular flap options available for total/subtotal rhinectomies and nasal lining reconstruction	Review	Various Free Flaps	Total/Subtotal Rhinectomy	N/A
2018	Yen²⁹	Investigated the use of fasciocutaneous ALT flaps for nasal resurfacing in patients with burn injuries	Clinical Study	Free ALT Flap	Nasal Surface (Burns)	6
2019	Ramji²⁸	Microvascular lining options for subtotal and total nasal reconstruction	Scoping Review	Various Free Flaps	Subtotal/Total Lining	65
2021	Son²²	Technique for reconstructing complex nasal/facial defects using a thinned ALT flap for improved outcomes	Case Series	Thinned ALT	Complex Nasal/Face	8
2021	Bali³	Total nasal reconstruction using a pre-laminated, super-thin ALT flap	Case Report	Thinned ALT	Total Nasal	1
2021	Pinto⁸	An aesthetic approach to total nasal defects using both ALT and RFF	Retrospective	ALT and RFF	Total Nose	10
2022	Hsu⁵	Utilized a chimeric ALT flap (incorporating vastus lateralis muscle) with double skin paddles to reconstruct the nasal airway and maxilla	Comparative Study	Chimeric ALT Flap	Nasal Airway/Maxilla	10
2022	Aliotta²⁷	free vascularized fascia lata flap specifically for total columella reconstruction	Case Report	Free Fascia Lata (ALT)	Total Columella	1
2023	Yen²	Free flap (ALT or MSAP) for lining in conjunction with a forehead flap for total nasal reconstruction	Case Series	ALT/MSAP Lining	Total Nasal	5
2025	Son²¹	Reconstruction of a complex defect involving the total nose and upper lip using a thinned chimeric ALT flap	Case Report	Thinned Chimeric ALT	Total Nose/Upper Lip	1
2025	Son²⁴	The versatility of multipedicled chimeric ALT flaps for reconstructing complex facial tissues	Retrospective	Multipedicled Chimeric ALT	Complex Facial Tissue	23

Evolution of the ALT Flap: From Volume Replacement to Differential Contouring

Historically, the limited use of the ALT flap in nasal reconstruction was due to its reluctance to be thinned. Its inherent bulk made it less suitable for detailed three-dimensional reconstruction, especially compared with the radial forearm flap. Early literature focused on its application for surface coverage rather than complete structural reconstruction. For example, Livaoglu et al. mainly described using the ALT flap for full-thickness nasal defect coverage.²² In our initial experience, we also used the ALT flap for total nasal and lining reconstruction in a radiated patient, providing reliable coverage but lacking aesthetic refinement (Figure 1). A significant breakthrough occurred with the development of perforator-based thinning techniques, which enhanced the ALT flap’s versatility. By adopting thin perforator methods, inspired by Kimura’s principles, we were able to safely thin the flap to about 4–8 mm without compromising vascular reliability. This approach enabled us to use the ALT flap for both external coverage and internal lining, resulting in better contour definition and less soft-tissue bulk than with traditional free flaps.

Figure 1.

(A) A 37-year-old male patient with a full-thickness nasal defect. (B) Two ALT skin paddles flap reconstruction of the nasal envelope and internal lining. (C) Two-year postoperative result

Two main thinning methods are recognized. Primary thinning involves removing deep fat tissue between the superficial fascia and fascia lata, while preserving a cuff around the perforator and subdermal plexus.^31-33 This technique reduces bulk and aids in dorsal resurfacing and envelope reconstruction, but often lacks the finesse needed for lining or tip refinement. Based on our experience, reconstructions with primary thinning sometimes required secondary debulking to improve contour. Microdissected thinning, performed under magnification, allows for targeted removal of superficial fat lobules while preserving perforator branches to the subdermal network. When perforator anatomy is suitable, this method can significantly reduce thickness, making the ALT flap as pliable as thinner free flaps. As a result, the flap can be used for full-thickness reconstruction, including internal lining and refined nasal subunits.

Beyond basic debulking, the evolution of the ALT flap has advanced toward differential contouring, with variable thickness tailored to nasal subunits: maximal thinning at the tip, alae, and columella for better projection and definition, while maintaining volume centrally for dorsal support. Preserving adipose tissue around the perforator ensures good perfusion and allows regional shaping. This graduated approach enables true three-dimensional modeling rather than uniform volume removal, improving structural stability and airway patency. The choice of thinning technique remains dependent on the perforator’s anatomy. Microdissection is safest when the perforator penetrates the superficial fascia perpendicularly, whereas oblique perforators branching parallel to the fascia pose a higher risk of vascular compromise and require fascial preservation. Therefore, not all perforator patterns are suitable for thinning.

Further developments include hybrid and multipaddle configurations. Multiple perforators from the lateral circumflex femoral system enable the harvesting of independent skin paddles from a shared pedicle, facilitating simultaneous reconstruction of the envelope, lining, and adjacent facial subunits in a single stage (Figures 2-5). Compared to single-paddle options, hybrid designs provide greater spatial flexibility and lower tension during inset in large composite defects. Overall, the evolution of the ALT flap for nasal reconstruction can be viewed in three phases: reduction (primary thinning to control bulk), integration (microdissection for full-thickness and lining reconstruction), and customization (differential thinning and hybrid configurations for complex 3D defects). Together, these improvements go beyond incremental technical gains; they transform the reconstructive approach for complex nasal defects. By combining controlled thinning, anatomy-guided microdissection, and hybrid setups, the ALT flap shifts from a secondary volume substitute to a primary, adaptable reconstructive option. In our experience, this method allows simultaneous restoration of the coverage, lining, and composite facial parts within a unified surgical plan, broadening the use of the ALT flap beyond traditional limits.

Figure 2.

(A) A 28-year-old female patient with post-burn scarring of the nasal dorsum and left cheek. (B) Two ALT skin paddles thinned to 6 mm for reconstruction of the nasal dorsum and left cheek. (C) Eighteen-month postoperative result

Figure 3.

(A) A 60-year-old female patient with basal cell carcinoma involving the nose, cheek, and upper eyelid, presenting with cutaneous defects following tumor excision. (B) Two ALT skin paddles thinned to 4 mm for reconstruction of the nasal envelope and internal lining. (C) Eight-year postoperative result

Figure 4.

(A) A 34-year-old male patient with acid burn scars. (B) Two ALT flaps were used for reconstruction of the nose and upper lip; the flap used for total nasal reconstruction was thinned to 4 mm. (C) Seven-year postoperative result

Figure 5.

(A) A 60-year-old male patient with squamous cell carcinoma presenting with total nasal and upper lip defects following tumor resection. (B) Two ALT flaps were harvested; the flap used for nasal reconstruction underwent customized thinning. (C) Sixteen-month postoperative result

The article still has some limitations. First, the clinical cohort is relatively small, which may restrict how well the results apply to a broader patient group. Second, the success of thinning techniques heavily depends on individual perforator anatomy. Microdissection is mainly feasible when perforators penetrate the superficial fascia at a right angle; oblique perforators branching parallel to the fascia carry a higher risk of vascular compromise and may not be suitable for extreme thinning. Third, while thinned ALT flaps offer better pliability, they still lack an ideal match in color and texture compared to the facial skin provided by the gold-standard forehead flap. Additionally, the technical complexity of microdissected thinning requires advanced microsurgical skills and may extend operative time. Furthermore, long-term aesthetic validation was constrained by the retrospective nature of the older historical cases within this cohort; a formalized, universally validated objective grading scale was not utilized at the time of follow-up, relying instead on subjective clinician and patient panels.

Conclusion

Reconstructing complex subtotal and total nasal defects requires a flexible donor site capable of providing multiple tissue types. Our experience alongside the literature show that the ALT flap has become a dependable, versatile choice for these repairs. Microdissection thinning and multipedicled chimeric designs allow simultaneous restoration of the nasal envelope, internal lining, and adjacent subunits when needed. This method improves free tissue transfer efficiency, ensures vascular reliability, and results in acceptable donor-site morbidity. For suitable patients, the thinned ALT flap provides a reliable, single-stage microsurgical solution for functional airway reconstruction and better aesthetic contouring.

Footnotes

ORCID iD

Phan Tuấn Nghĩa

Ethical Considerations

All procedures performed in studies involving human participants were in accordance with the ethical standards of our institutional committee (Ref: 136/QD-DHYHN) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent to Participate

All participants provided written informed consent before enrolment in the study. The privacy and confidentiality of patient records were adhered to in managing the clinical information in conducting this research.

Authors’ Contributions

Trần Thiết Sơn: Project administration, Conceptualization, Writing - Original Draft, Writing - Review & Editing, Supervision.

Phan Tuấn Nghĩa: Formal analysis; Writing - Review & Editing.

Đặng Phương Nam: Methodology, Resources; Data Curation.

Tuấn Anh Hoàng: Visualization.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.*

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