Soft-tissue reconstruction using a free anterolateral thigh flap: experience with 28 patients

The authors present their experience using the free anterolateral thigh fasciocutaneous flap for head and neck and extremity reconstruction. From January 2000 through March 2002, 28 free anterolateral thigh flaps were transferred to reconstruct various soft-tissue defects. All patients were operated by two teams. All flaps were elevated based on one perforator only. The sizes of the flaps ranged from 9 x 11 to 20 x 26 cm. The success rate was 96.5% (27 of 28), with one partial failure. The cutaneous perforators were always found. Septocutaneous perforators were found in 3 of 28 patients (10.7%). Musculocutaneous perforators (89.3%) were found in the remaining patients, and the number of perforators ranged from two to five (average, three perforators). In 4 patients, flaps were used for sensate reconstruction. The authors used the anterolateral thigh flap as a thin flap in 10 patients. Mean follow-up was 13.5 months (range, 2-25 months). Soft-tissue reconstruction with the free anterolateral thigh flap in various regions of the body provides an excellent functional and cosmetic result with minimal donor site morbidity. The anterolateral thigh flap has many advantages over other conventional free flaps and it seems to be an ideal choice for the reconstruction of soft-tissue defects.     

The use of free anterolateral thigh flap for reconstructing soft tissue defects of the lower extremities

The goal of soft tissue reconstruction in the lower extremities is to provide a functional and cosmetically acceptable limb. The anterolateral thigh flap has become one of the most popular options for soft tissue defect reconstruction recently because of the large amount of skin available and the reliable and versatile nature of this material. The purpose of this article is to present our experiences with the free anterolateral thigh flap for the reconstruction of soft tissue defects of the lower extremity. From April 2002 to October 2003, 31 consecutive free anterolateral thigh flaps were used. There were 24 male and 7 female patients, and their ages were between 3 and 78 years. The size of the flaps ranged from 11 to 34 cm long and 6 to 16 cm wide. In 9 patients, the flaps were harvested in a flow-through manner to both reconstruct soft tissue defects and protect and maintain the vascular status of the lower extremities. In these patients, the pedicle was interposed between vascular gaps, either present or created, in the extremity. The patency of distal anastomosis with the course of the distal vessel was confirmed by using conventional Doppler flow monitoring in flow-through flaps. In 4 cases, thinning of the flap was performed. In 3 patients, flaps were used in a neurosensorial fashion. Four flaps required reoperation due to vascular compromises. While 3 of these were salvaged, 1 flap was lost due to recipient arterial problems. Sixteen cases underwent split-thickness skin grafting of the donor site. No infection or hematomas were observed. We conclude that the anterolateral thigh flap is an ideal and versatile material, especially for lower extremity reconstructions, with its functional and cosmetic advantages, and it can be considered a suitable alternative to the most commonly used conventional soft tissue flaps.     

An ideal and versatile material for soft-tissue coverage: experiences with most modifications of the anterolateral thigh flap

Free anterolateral thigh flaps are a popular flap used for the reconstruction of various soft-tissue defects. From April, 2002 to June, 2003, 32 free anterolateral thigh flaps were used to reconstruct soft-tissue defects. Twenty-three of these flaps were used for lower extremity reconstruction, and nine were used for head and neck reconstruction. There were 24 male and eight female patients, with ages between nine and 82 years. The size of the flaps ranged from 11 to 32 cm in length and 6 to 18 cm in width. Five flaps required reoperation for vascular compromise in four patients and for twisting of the pedicle in another patient. While four of these were salvaged, one flap was lost due to recipient vessel problems. Musculocutaneous perforators were found in 23 cases, and septocutaneous perforators were found in nine cases. In four cases, thinning of the flap was performed. The flap was used as a flow-through type for lower extremity reconstruction in three patients. In two patients, the flap was used as a neurosensory type for foot reconstruction. Eighteen cases underwent split-thickness skin grafting of the donor site and, in the remaining cases, the donor sites were closed primarily. In three patients, the donor areas required a partial skin regrafting procedure. No infections or hematomas were observed. Despite some variations in its vascular anatomy, the anterolateral thigh flap offers the following advantages: 1) it has a long and large-caliber vascular pedicle; 2) it has a wide, reliable skin paddle; 3) it may be harvested as a neurosensory flap; 4) it can be harvested whether its pedicle is septocutaneous or musculocutaneous; 5) it can be designed as a flow-through flap; 6) it can be elevated as a thin or musculocutaneous flap; and 7) the procedure can be performed by two teams working simultaneously, and no positional changes are required.     

To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects.

The anterolateral thigh (ALT) flap has achieved popularity recently for free-flap reconstruction of intraoral defects following excision of squamous cell carcinoma. We have assessed the feasibility of the ALT flap as a free flap for oral lining and the potential use of the thinned ALT flap in a one-stage reconstruction. We used the ALT flap to reconstruct the oral cavity in 18 consecutive patients between December 2000 and December 2001 following intraoral resection of squamous cell carcinoma. Twelve patients underwent reconstruction using a standard ALT flap, four patients received a thinned ALT flap in a one-stage procedure, one patient received a standard ALT flap in combination with a fibula flap and one patient received a combination of a standard ALT flap and vascularised iliac bone. There were no complications in any of the 14 cases in which a standard ALT flap was used. Two of these flaps were thinned subsequently as secondary procedures. Of the four thinned ALT flaps, one flap failed completely and two flaps experienced partial necrosis. In all but one case the donor site was closed directly with minimal donor-site morbidity. The ALT flap is a versatile flap that can be used in combination with other flaps for more complex defects with minimal donor-site morbidity and is a useful alternative in the armamentarium of the head and neck surgeon. Thinning of the flap is best performed as a secondary procedure, should it be required.     

Reconstruction of lower extremity complex wounds with combined free tissue transfer using the anterolateral thigh flap as a link

In this report, the authors present the experience on the reconstruction of the totally degloved foot and extremely long soft tissue defect of a lower limb with the combined free tissue transfer using the anterolateral thigh flap as a link in two male patients between October 2009 and December 2010. The anterolateral thigh flap has been commonly used as a link between the recipient site and the distal flap. The anterolateral thigh flap and latissimus dorsi muscle flap were selected for the distal flap, according to their reconstructive needs. Two combined free flaps survived without major complication. The authors could salvage of the lower extremity through the reconstruction of complex wound with the combined free tissue transfer using the anterolateral thigh flap as a link. This combined flap may be an alternative for reconstruction of complex soft tissue defect in the lower extremity. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Free anterolateral thigh flap for reconstruction of head and neck defects: preliminary results and a comparison with the radial forearm flap

BACKGROUND: The authors present their personal preliminary experience with the free anterolateral thigh flap in the reconstruction of head and neck defects and compare these first cases with the radial forearm flaps. METHODS: Seventeen patients undergoing free flap reconstruction between December 1998 and September 2001 have been selected for this retrospective study and evaluated. In fourteeen patients reconstruction was performed with a radial forearm flap. In three patients an anterolateral thigh flap was used. Six dissections on cadavers have also been performed in order to study the anatomical variations of the perforators of the lateral circumflex femoral system. RESULTS: All flaps survived, without any major vascular impairment. CONCLUSIONS: Despite a laborious dissection of the pedicle the anterolateral thigh is a versatile flap, with a minimal morbidity of the donor area. Even if the radial forearm is overall accepted as the gold standard for head and neck reconstruction, the anterolateral thigh flap is suggested as a good and safe surgical option, especially when a large flap is requested or in female patients concerned with the cosmetic result in the forearm donor area.     

Lateral thigh free flap with flow-through vascular pedicle

The lateral thigh flap based on the second and third perforator of profunda femoris vessel has not become very popular. We describe a technique of flow-through pedicle for this flap. The flow-through technique makes this flap very simple to transfer. The flap was used successfully in 6 cases for reconstruction for defects in the leg and forearm. The flow-through pedicle is ideal for lower limb reconstruction. The anastomosis becomes very easy and safe, even if the recipient vessels are deep in the intermuscular septum. We had no flap failures. The flap has a very predictable anatomy. Large flaps from anteriolateral and posterior part of midthigh can be safely elevated. The flap can meet a variety of requirements as it can be thin skin-alone flap, a fasciocutaneous flap, or even a musculocutaneous flap. A simple pinch test gives a fair idea of expected flap thickness. The dissection requires strong retraction of the anterior thigh muscles, but the dissection is safe and simple. The donor-site morbidity is very minimal.     

Comparison of anterolateral thigh and radial forearm free flap donor site morbidity

This study evaluated patient-reported outcome of the donor site in patients following head and neck cancer reconstruction. Patients who had undergone cancer reconstruction using either an anterolateral thigh or a radial forearm free flap and who were at least 6 months postsurgery were included and contacted by telephone. There were 37 patients (mean age 61 years, standard deviation 16 years) with 18 anterolateral thigh flaps and 19 radial forearm flaps. The majority of patients were not bothered by scar appearance, light touch, numbness or pain. Significantly more females (P = 0.038) and more patients with radial forearm flaps (P = 0.045) were bothered by the cold at the donor site and more females reported that the shape of the operated extremity was different (P = 0.009). Donor site morbidity is not significant following a radial forearm or anterolateral thigh free flap and the reconstruction should be based upon individual patient factors and surgeon expertise.     

股前外侧穿支皮瓣桥接旋髂浅动脉蒂组织瓣组合移植修复四肢骨与软组织缺损

目的 探讨股前外侧穿支皮瓣桥接旋髂浅动脉蒂组织瓣组合移植修复四肢骨与软组织缺损的应用特点.方法 回顾性分析2009年3月至2011年1月,用股前外侧穿支皮瓣制备血流桥接皮瓣串联旋髂浅动脉为蒂的髂骨骨皮瓣、髂骨膜骨瓣或皮瓣修复10例四肢骨与软组织缺损患者资料,男9例,女1例;年龄21～57岁,平均39.7岁;血流桥接髂骨骨皮瓣7例,髂骨膜骨瓣2例,髂腹股沟皮瓣1例;重建手3例,足4例,小腿3例;平均皮肤缺损面积20 cm×9.7 cm.结果 股前外侧穿支皮瓣平均17.8 cm×9.4 cm,髂腹股沟皮瓣平均8.4 cm×4.5 cm,髂骨膜骨瓣平均5.4 cm×2.1 cm×0.8 cm,血管桥平均长10.5 cm.1例髂骨骨皮瓣远端部分坏死,经换药后植皮愈合,余皮瓣顺利成活.10例患者均获得6～36个月(平均12个月)随访.手损伤者平均骨愈合时间3个月,平均臂肩手残疾问卷评分43分;足损伤者平均骨愈合时间4个月,日本外科协会足部疾患治疗效果评分平均71.3分;小腿损伤者平均骨愈合时间4.5个月,Puno等评分平均91分.供区瘢痕颜色白、平软,6例大腿瘢痕增宽,2例瘢痕周围有麻木感,3例髂腹股沟区瘢痕增宽.结论 股前外侧穿支皮瓣桥接旋髂浅动脉蒂组织瓣移植可自由调整组织瓣位置,供区副损伤小,是修复大面积、结构复杂或类型特殊四肢骨与软组织缺损的一种较好方法.     

Free anterolateral thigh flap in pediatric patients

The anterolateral thigh (ALT) flap represents a workhorse flap in reconstructive surgery. We describe our clinical experience with this flap in the pediatric population. A total of 20 patients with an average age of 9.5 years underwent a free ALT flap reconstruction. All flaps were commonly raised on 2 perforators. About 5 flaps were employed for head and neck reconstruction, 7 for upper and 8 for lower limb reconstruction. Traumatic defects and congenital malformations represented the predominant etiology. Sizable perforators were found in all patients. The caliber was smaller compared to adults, and the course of the perforator was shorter. There were no complete flap losses and no significant donor-site morbidity. Donor-site closure required closure with split-thickness skin grafts in 6 cases. Hypertrophic scars developed in 4 patients. Secondary procedures included flap debulking (5) and Z-plasties (2). In conclusion, children have well-developed perforators supplying the ALT flap. With proper technique, this flap can be harvested and employed safely and reliably for reconstruction of varied defects in children.     

Customized reconstruction with the free anterolateral thigh perforator flap

From April of 2003 through September of 2006, 70 free anterolateral thigh (ALT) flaps were transferred for reconstructing soft-tissue defects. The overall success rate was 96%. Among 70 free ALT flaps, 11 were elevated as cutaneous ALT septocutaneous vessel flaps. Fifty-seven were harvested as cutaneous ALT myocutaneous "true" perforator flaps. Two flaps were used as fasciocutaneous perforator flaps based on independent skin vessels. Fifty-four ALT flaps were used for lower extremity reconstruction, 11 flaps were used for upper extremity reconstruction, 3 flaps were used for trunk reconstruction, and 1 flap was used for head and neck reconstruction. Total flap failure occurred in 3 patients (4.28% of the flaps), and partial failure occurred in 5 patients (7.14% of the flaps). The three flaps that failed completely were reconstructed with a free radial forearm flap, a latissimus dorsi flap and skin grafting, respectively. Among the five flaps that failed partially, three were reconstructed with skin grafting, one with a sural flap, and one with primary closure. The free ALT flap has become the workhorse for covering defects in most clinical situations in our center. It is a reliable flap with consistent anatomy and a long, constant pedicle diameter. Its versatility, in which thickness and volume can be adjusted, leads to a perfect match for customized reconstruction of complex defects.     

The prefabricated gracilis muscle flap with full-thickness skin graft and delay for urethral channel reconstruction

Fasciocutaneous free flaps are commonly used in reconstruction of the lower extremity. The purpose of this study was to compare preferences in donor-site scar location among 3 flaps capable of covering a wound that is 4 to 6 cm wide with primary closure of the donor-site. The locations chosen were the lateral arm, the anterolateral thigh, and the proximal lateral calf. Survey participants were presented a hypothetical scenario of a trauma patient with an open anterior tibial wound, requiring free flap reconstruction. In an internet-based survey, respondents were asked to take on the role of the patient and to rate the 3 donor-site scar locations with a visual analog scale and rank them in order of preference. One hundred ninety-eight respondents (mean age 24.7 ± 2.9 years, 49.1% men) responded to the survey, and 171 were included. The anterolateral thigh was the most preferred donor site (88.9% ranked first, rated 8.24 ± 1.86), followed by the proximal lateral calf (8.7% ranked first, rated 5.03 ± 1.96), and the lateral arm was last (2.3% ranked first, rated 2.18 ± 1.62). Survey participants clearly preferred the anterolateral thigh as a donor site. This preference may be related to the ability to conceal the scar under clothing, whereas the proximal lateral calf could keep scars in a smaller topographical area of the body. When other aspects of the reconstruction are equal, it may be important for the surgeon and patient to discuss the goals of concealing the donor-site scar versus keeping the wound and reconstruction-related scars in a smaller topographical area of the body.     

Microsurgical free flap transfer to amputation sites: indications and results

A series of microsurgical free flap reconstructions to amputation stumps of the upper as well as the lower extremities was reviewed in 7 male and 2 female patients. Indications included preservation of length after trauma in 6 patients and cure of local infection in 2 patients. In 1 patient an extensive defect after resection of a recurrent shoulder sarcoma required use of a complete arm fillet free flap for tumor reconstruction. Microvascular free flaps used included four scapular flaps, two fillet flaps from the amputated extremity, one anterolateral thigh flap, and one lateral arm flap. Seven of 9 patients were fitted with a prosthesis and underwent occupational therapy resulting in ambulatory and improved functional status. Microvascular reconstruction is indicated in emergency settings as well as for elective reconstruction of amputation sites. Using uninjured "spare parts" of the amputated extremity should be considered. Elective reconstruction is performed preferably with free flaps based on the subscapular vascular system.     

Versatility of the lateral arm free flap in various anatomic defect reconstructions

The free lateral arm flap may be harvested as a fascial, fasciocutaneous, or osteofasciocutaneous flap. Simultaneous flap elevation with preparation of the recipient site, easy dissection, minimal donor-site morbidity, and a constant vascular anatomy with long pedicle are advantages of the flap. In this study, the authors present 18 patients operated on between January, 2002 and August, 2003 in whom 18 free lateral arm flaps were utilized. There were four women and 14 men, and the mean patient age was 40 years. Thirteen fasciocutaneous, three fascial, and two osteofasciocutaneous flaps were used. Flaps were employed for the reconstruction of the lower extremity in five patients, upper extremity in nine patients, and head and neck in four patients. Thirteen flaps were elevated under axillary block and five flaps under general anesthesia. Aspirin, dipirydamol, dextran, and chlorpromazine were administered postoperatively. Venous insufficiency developed in two lower-extremity reconstructions on postoperative day 1. Venous thromboses were detected, anastomoses were re-done, and flaps healed uneventfully. No other postoperative complication was observed in the other patients. The free lateral arm flap may be used in various anatomic defects with various indications. It may be elevated under axillary block for extremity reconstructions.     

Free radial forearm osteocutaneous perforator flap for reconstruction of total nasal defects

A case in which a radial forearm osteocutaneous perforator flap was successfully transferred for one-stage reconstruction of total nasal loss is described. This thin flap consists of vascularized radial bone, superficial adiposal tissue, and no deep fascia. It is nourished by a single perforator of the radial artery and a cutaneous vein. The advantages of this flap are minimal donor-site morbidity, easy reconstruction for preservation of the radial arterial system, and no need for longer dissection through the radial artery. The donor defect can be repaired with a flow-through flap, such as an anterolateral thigh flap or a latissimus dorsi perforator flap.     

Bilateral anterolateral thigh flaps for large-volume breast reconstruction

Autologous tissue reconstruction of a large breast in patients who are not candidates for a TRAM flap is a difficult problem. We present a case report of the use of bilateral free anterolateral thigh (ALT) flaps for immediate reconstruction of a unilateral large breast in a patient who had a previous abdominoplasty. Use of ALT flaps allows two or three surgical teams to work simultaneously, does not require intraoperative patient repositioning, has minimal donor-site morbidity, and can provide ample malleable soft tissue for breast reconstruction. These are advantages compared to the use of gluteal donor sites. The disadvantages include more conspicuous donor-site scarring on the anterior thighs.     

Versatility of the free anterolateral thigh flap: clinical experience in a series of 20 patients

The main nutrient vessel of the anterolateral thigh flap is the perforator originating from the descending branch of the lateral circumflex femoral artery (LCFA). It supplies a large area of skin on the anterolateral aspect of the thigh. We present the experience of 20 consecutive anterolateral thigh flaps used for a variety of soft tissue defects. Fourteen flaps were used for lower leg reconstruction, four in the head and neck, and the remaining two in the hand. The largest flap was 30᎗ cm. All flaps survived except two which had partial skin necrosis, but the underlying adipose tissue survived and was grafted. Reexploration was needed for one patient in whom a thrombus blocking the vein was removed, and the flap survived completely. The anterolateral thigh flap has the advantage of a long vascular pedicle, large-caliber vessels, availability of a large skin flap area, and suitability as a flow-through flap.     

Rationale for reconstruction of large scalp defects using the anterolateral thigh flap: structural and aesthetic outcomes

The advent of free tissue transfer has provided multiple options that allow preservation and maintain both the structural and aesthetic status of the scalp. Since the first report of the anterolateral thigh flap in 1984, it has become one of the most commonly used flaps for the reconstruction of various soft-tissue defects. Eleven free anterolateral thigh flaps were used to reconstruct soft-tissue defects of different regions of the scalp. Two of these flaps were used for the occipital region, six for temporal regions, two for the frontoparietal midline region, and the remaining flap for a defect of the forehead. The study consisted of 10 males and one female whose ages ranged from 18 to 82 years (mean age: 52.5 years). Six patients had primary or recurrent cancer, four had acute or subacute wounds resulting from trauma or craniotomy, and one had high-tension electrical burn injury. The size of the flaps ranged from 14 to 27 cm in length and from 6 to 18 cm in width. The overall flap success rate was 100%. In two cases, primary thinning of the flap was performed to reconstruct a tissue defect of the temporal region in one patient and a forehead defect in the other. In two patients, the fascial layer of the flap was used as a source for a vascularized fascial flap to cover defects of the dura mater. No secondary corrections, including debulking procedures or scar revision, were necessary. No infections or hematomas were observed. Six cases underwent split-thickness skin grafting of the donor site and, in the remaining cases, the donor sites were closed directly. No donor-site morbidity was observed. The authors conclude that with its evident structural and cosmetic advantages, the anterolateral thigh flap can be considered an excellent flap option for most scalp defects.     

One-stage reconstruction of large scalp defects: anterolateral thigh flap

Seven patients with large scalp and calvarial defects underwent reconstruction with free tissue transfer. Patients fell into two groups according to etiology: tumoral (five) or traumatic (two). A single type of free flap was used in each patient, i.e., the anterolateral thigh flap. Duraplasties with the flaps' vascularized fasciae were performed in two patients with minor calvarial defects, and nonvascularized fasciae were used in another two, with a cranioplasty using methylmethacrylate. One postoperative death and one venous congestion necessitating exploration were observed. The explored anastomosis revealed occlusion of the venous anastomosis; drainage with a venous graft into the neck veins was performed. Minor tissue loss with secondary healing was observed in the flap. Extensive scalp defects often necessitate challenging reconstructive procedures. Single-stage reconstruction with good qualified tissue is possible with a free tissue transfer. The anterolateral thigh flap provides a large amount of tissue with decreased donor-site morbidity and good cosmetic results.     

Pedicled deep inferior epigastric perforator flap for lower abdominal defects and genital reconstructive surgery

The pedicled deep inferior epigastric perforator (DIEP) flap can be used successfully to reconstruct the lower abdominal, inguinal, and genital regions. This muscle-sparing technique offers many advantages, such as minimal donor-site morbidity, a wide arch of rotation, and more versatile flap design, and provides for easier reconstruction than free flaps. Four pedicled DIEP flap cases are described in this article. The flaps were used to reconstruct lower abdominal defects and groin defects and to perform a penile reconstruction. To the best of our knowledge, ours is the first report in the English literature to describe the use of a pedicled DIEP flap for penile reconstruction. The donor sites were closed directly, and morbidity in all cases was minimal.