Single free anterolateral thigh flap for simultaneous reconstruction of composite hypopharyngeal and external neck skin defect after head and neck cancer ablation

Single flap for complex hypopharyngoesophageal and anterior neck skin defect reconstruction is still a challenge for reconstructive surgeons. Herein, we present five patients, with advanced hypopharyngeal cancer and anterior neck skin invasion, which received a single anterolateral thigh (ALT) fasciocutaneous flap for composite inner pharyngeal and outer skin defect reconstruction after wide composite resection. Two ALT flaps were divided into two distinct paddles supplied by two or more separate perforators, one part for reconstructing the inner pharyngeal defect and another for neck skin coverage. Three ALT flaps only supplied by one sizable perforator could not be divided and de‐epithelization of mid‐part had to be done to reconstruct both defects with the single flap. The results revealed survival of all flaps. There were no flap loss, fistulas, or bleeding complications. All patients recovered uneventfully and could eat a soft diet to regular diet postoperatively. In conclusion, one‐staged reconstruction of complex pharyngoesophageal and external skin defects after extensive oncological resection is feasible using a single ALT fasciocutaneous free flap. © 2011 Wiley‐Liss, Inc. Microsurgery, 2011.     

Monitoring a free anterolateral thigh flap for pharyngeal reconstruction

Aim: To describe a novel way of monitoring a buried fasciocutaneous anterolateral thigh (ALT) flap used for pharyngeal reconstruction. Methods: A tubed ALT flap was used to reconstruct a circumferential pharyngeal defect following resection of a carcinoma. An island of skin based on a separate perforator and externalized through the neck incision was used to monitor the flap. It was removed as a bedside procedure on the fifth postoperative day. Results: The externalized skin island allowed easy monitoring of the buried tubed free‐flap used to reconstruct the pharynx. Simple clinical parameters such as temperature, colour and capillary refill were used to monitor the flap instead of more complex and invasive methods. Conclusion: When feasible, a second skin island based on a separate set of perforator vessels provides an easy, safe and simple method of monitoring a buried free‐flap.     

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.     

Flow-through anterolateral thigh flap for a free osteocutaneous fibula flap in secondary composite mandible reconstruction.

Head and neck reconstruction after tumour ablation and radiotherapy often requires complex surgery. The need for free composite tissue transfer and the poor quality of the recipient site increase the level of difficulty substantially. We report a case in which the mandible, floor of the mouth and skin of the neck needed to be reconstructed in a heavily irradiated field. A single osteocutaneous fibula flap was insufficient to reconstruct the defect, and a free anterolateral thigh (ALT) flap was also used for external neck skin resurfacing. As the recipient vessels in the ipsilateral neck had been heavily irradiated the free ALT flap was used as an interposition conduit for the free osteocutaneous fibula flap enabling it to reach the healthy recipient vessels in the contralateral neck without needing vein grafts.     

The composite anterolateral thigh flap for knee extensor and skin reconstruction

The simultaneous reconstruction of a skin defect and lost extensor mechanism of the knee joint is difficult. We present a 31-year-old male who lost the patella and had a 9 × 10 cm skin defect after a total patellectomy for an infected open patellar fracture. A composite anterolateral thigh (ALT) flap including vascularized skin and fascia lata (FL) was elevated. The FL was folded and sutured to the remaining patellar tendon. The skin flap covered the skin defect. The wound healed uneventfully. Thirty months later, the active range of motion of the knee joint was 0°–120° and the extension strength of the knee joint was normal. He could stand on his right leg and walk without assistance. The composite ALT flap is a valuable option in knee reconstruction after a total patellectomy.     

Reconstruction of an upper posterior thigh extensive defect with a free split‐anterolateral thigh (s‐ALT) flap by perforator‐to‐perforator anastomosis: A case report

The anterolateral thigh (ALT) flap is one of the most commonly used flap worldwide in reconstructive surgery, as both free flap and pedicled local flap. Here, we report the use of a free split anterolateral thigh (s‐ALT) flap for reconstruction of a 14 cm × 16 cm soft tissue defect of the left upper posterior thigh region due to sarcoma resection in a patient. The ALT flap was harvested based on two musculocutaneous perforators from the right thigh and anastomosed to the contralateral descending branch of the lateral circumflex femoral artery (LCFA) in perforator‐to‐perforator manner, in order to gain more pedicle length and being able to cover the posterior thigh defect. The post‐operative course was uneventful and the patient was discharged at 1 week post‐operative. Eleven months after the operation, the aesthetic outcome was satisfactory with no functional deficit. Even though it requires technical skills and experience in perforator dissection, we believe that the s‐ALT flap anstomosed to the contralateral LCFA in perforator to perforator fashion, may be a good solution in case of such a difficultly located extensive defect of the posterior thigh.     

Total scalp reconstruction with bilateral anterolateral thigh flaps

Large scalp defects can require complicated options for reconstruction, often only achieved with free flaps. In some cases, even a single free flap may not suffice. We review the literature for options in the coverage of all reported large scalp defects, and report a unique case in which total scalp reconstruction was required. In this case, two anterolateral thigh (ALT) flaps were used to resurface a large scalp and defect, covering a total of 743 cm(2). The defect occurred after resection and radiotherapy for desmoplastic melanoma, with several failed skin grafts and local flaps and osteoradionecrosis involving both inner and outer tables of the skull. The reconstruction was achieved as a single-stage reconstruction and involved wide resection of cranium and overlying soft-tissues and reconstruction with calcium phosphate bone graft substitute, titanium mesh, and two large ALT flaps. The reconstruction was successfully achieved, with minor postoperative complications including tip necrosis of one of the flaps and wound breakdown at one of the donor sites. This is the first reported case of two large ALT flaps for scalp resurfacing and may be the largest reported scalp defect to be completely resurfaced by free flaps. The use of bilateral ALT flaps can be a viable option for the reconstruction of large and/or complicated scalp defects.     

Computed tomography angiography imaging for the chimeric anterolateral thigh flap in reconstruction of full thickness buccal defect

Background: Microvascular free flap transplantation is the current most common choice for reconstruction of difficult through‐and‐through buccal defect after cancer extirpation. The chimeric anterolateral thigh (ALT) flap is an ideal flap to cover this full thickness defect, but variation in the location of perforators is a major concern. Herein, we introduce computed tomographic angiography (CTA)‐guided mathematical perforators mapping for chimeric ALT flap design and harvest. Methods: Between September 2008 and March 2009, nine patients with head and neck tumour underwent preoperative CTA perforator mapping before free ALT flap reconstruction of full thickness buccal defects. The perforators were marked on a 64‐section multi‐detector CT image for each patient, and the actual perforator locations were correlated with the intra‐operative dissection. The donor limb of choice, either right or left, was also selected based on the dominant vascularity. Flap success rates, any associated morbidity and complications were recorded. Results: A total of 23 perforators were identified on CTA image preoperatively. Twenty‐two of these perforators were chosen for chimeric flap design, and all were located as the CTA predicted, with the rate of utilization being 95.7% (22/23). There were two post‐operative complications, including one partial flap necrosis and one microstomia. All of the ALT flaps survived, and there was no donor site morbidity. Conclusions: Preoperative CTA allows accurate perforator mapping and evaluation of the dominant vascularity. It helps the surgeon to get an ideal designing of the chimeric ALT flap with two skin paddles based on individual perforators, but only one vascular anastomosis in reconstruction of full thickness buccal defects.     

The combined free partial vastus lateralis with anterolateral thigh perforator flap reconstruction of extensive composite defects.

Myocutaneous (MC) free flaps are useful for many reconstructive indications. Perforator flaps have become standard of care. The anterolateral thigh flap (ALT) donor site is popular. With the ALT flap varying sizes of vastus lateralis (VL) muscle can be harvested as a MC flap. The skin islands of these flaps have a great range of freedom when dissected on their perforator. It was hypothesised that the VL-ALT perforator flap would offer adequate tissue volume combining maximal freedom in planning with minimal donor site morbidity. From November 2001 to February 2003 a free partial VL with ALT perforator flap was used in 11 patients to reconstruct large defects. Indications for adding a muscular component were exposed bone, skull base, (artificial) dura, or osteosynthesis material, open sinuses, and lack of muscular bulk. Flaps were planned as standard ALT flaps, after which three types of dissection were performed: I. true MC flap; II. muscle flap with a skin island on one perforator, which could be rotated up to 180 degrees ; III. chimera skin perforator flap with muscle being harvested on a separate branch from the source vessel or on a side branch of the skin perforator. Mean skin size of the MC-ALT flaps was 131 cm2. Mean muscle part size of the MC-ALT flaps was 268 cm3. Muscular parts were custom designed for all defects. No total or partial flap failures were seen. Colour mismatch was seen in 6 of 8 patients, when skin was used in the facial area in this all white population. Excessive flap bulk was found in 8 of 11 patients at 6 weeks, however, only in 2 of 11 patients after 6 months. Patients were satisfied with the functional result (8 of 11 patients) as well as the cosmetic result of their reconstruction (7 of 11 patients). All less satisfied patients had received their flap for external facial skin reconstruction. Donor site morbidity was minimal. The combined free partial VL with ALT perforator flap proved valuable as a (chimera type) MC flap with maximal freedom of planning to meet specific reconstructive demands and minimal donor site morbidity.     

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.     

A case of degloving injury of the whole hand reconstructed by a combination of distant flaps comprising an anterolateral thigh flap and a groin flap

A case of degloving injury of the whole hand reconstructed by a combination of an anterolateral thigh (ALT) flap and a groin flap applied as a pedicled distant flap was reported. Despite complications of congestion of the ALT flap and superficial infection, both flaps were severed at 4 weeks after transplantation, and a useful hand was finally reconstructed. The combination of a pedicled groin flap and an ALT flap is not optimal for reconstruction of a whole-hand degloving injury but is considered to be an available procedure for covering a large skin defect without microsurgical procedures.     

Simultaneous reconstruction of large maxillary and mandibular defects with a fibular osteocutaneous flap combined with an anterolateral thigh flap

This article reports the simultaneous reconstruction of maxillary and mandibular defects caused by a close-range gunshot blast to the face with one fibular osteocutaneous flap combined with an anteroateral fasciocutaneous flap. A fibular osteocutaneous flap was used for both mandibular and maxillary defects, using multiple osteotomies and discarding a central bony segment and an oral floor defect. An anterolateral thigh flap was used to cover a three-dimensional defect of both the intraoral mucosal region, as well as external skin and soft tissue defects, including some on the upper and lower lips. The results demonstrated that the method was a good choice in the reconstruction of large composite facial defects, both aesthetically and functionally.     

Reconstruction of extensive abdominal wall defect using an eccentric perforator‐based pedicled anterolateral thigh flap: A case report

Reconstruction of extensive abdominal wall defects is a challenge for reconstructive surgeons. In this report, a case of reconstruction of a large abdominal wall defect using an eccentric perforator‐based pedicled anterolateral thigh (ALT) flap is presented. A 30‐year‐old man presented with recurrent desmoid‐type fibromatosis in the abdominal wall. The recurrent tumor was radically excised, and the en bloc excision resulted in a full‐thickness, large abdominal wall defect (25 cm × 20 cm). An eccentric perforator‐based pedicled ALT flap, including wide fascial extension, was transferred to the abdominal defect; fascial portions were sutured to the remnant abdominal fascia. Plication of the fascia along the sutured portion was performed to relieve the skin tension between the flap and the marginal skin of the abdominal defect. Eight months after surgery, the reconstructed abdomen had an acceptable esthetic appearance without tumor recurrence or hernia. The use of an eccentric perforator‐based pedicled ALT flap may be an alternative method for the reconstruction of extensive abdominal wall defects. © 2013 Wiley Periodicals, Inc. Microsurgery 33:482–486, 2013.     

Use of the anterolateral thigh flap as an alternative to the rectus flap in obese and overweight patients

INTRODUCTION: Oncologic reconstruction in obese patients can be challenging. Donor tissues, such as the rectus flap, can be excessively bulky and result in significant cosmetic and functional deformities. Although the use of the anterolateral thigh (ALT) flap as an alternative to the radial forearm flap has been extensively described, few studies have evaluated the use of the ALT flap as an alternative to the rectus flap. The purpose of this study was to evaluate our experience with the ALT flap in overweight or obese patients. METHODS: A retrospective review was conducted of all ALT flaps performed over a 2-year period at Memorial Sloan-Kettering Cancer Center. All patients with a body mass index (BMI) >25 kg/m2 were identified and evaluated. RESULTS: Twenty-seven patients underwent ALT flap reconstruction during the study period. Of these, 11 patients were overweight (BMI, 25.1-30 kg/m2) or obese (BMI, >30 kg/m2). Reconstructions were performed for a variety of oncologic defects, including head and neck (n = 7), extremity (n = 2), chest wall (n = 1), and abdominal wall (n = 1). Complications were, in general, mild and infrequent. One patient experienced a minor infection, 1 patient had partial flap loss, and 2 patients had partial skin graft loss at the donor site. There were no flap losses. CONCLUSIONS: The ALT flap is a safe and reliable flap for reconstruction of diverse defects in overweight or obese patients. Large flaps can be designed and tailored to the defect by harvesting variable amounts of skin, subcutaneous tissues, fascia, and muscle. The ALT flap may be a good alternative to the rectus flap in overweight or obese patients.     

Extended anterolateral thigh pedicled flap for reconstruction of trochanteric and gluteal defects: A new & innovative approach for reconstruction

Descending branch of the lateral circumflex femoral artery (LCFA) is commonly used pedicle for anterolateral thigh (ALT) flap. Oblique branch of LCFA is an alternative pedicle that can be used in microvascular surgery. According to review of literature and to the best of our knowledge we could not find the use of oblique branch of LCFA as a pedicle of the ALT flap in regional soft tissue reconstruction. Here we presented a case of a 55-year-old man sustaining soft tissue injury and wound over the left trochanteric and gluteal region following a road traffic accident, who was treated by the use of extended ALT pedicle flap with oblique branch of LCFA as the pedicle for reconstruction of soft tissue defect in trochanteric and gluteal regions with successful outcome.     

Pedicled chimeric sensitive fasciocutaneous anterolateral thigh (ALT) and vastus lateralis muscle (VLM) flap for groin defect reconstruction: A case report

The anterolateral thigh (ALT) flap is one of the most commonly used flap worldwide, as both free flap and pedicled local flap. Here, we report the use of a pedicled chimeric sensitive ALT and vastus lateralis muscle (VLM) flap in a patient with a 12 cm × 8 cm contaminated soft tissue defect of the right inguinal region with exposed femoral vessels. The flap was harvested based on two perforators, one musculocutaneous and one pure muscular, each nourished separately a sensitive fasciocutaneous component and a vastus lateralis muscle component, respectively. The muscle part was tailored to wrap around the exposed vascular structures, while the innervated skin and fascia component of the flap provided a tension‐free closure of the wound. The post‐operative course was uneventful and the patient was discharged at 1 week post‐operative. Even though it requires technical skills and experience in perforator dissection, we believe that the pedicled chimeric sensitive ALT and VLM flap may be one of the best solutions in case of exposed femoral vessels in contaminated wounds.     

Using the proximal perforator‐based anterolateral thigh flap from the same donor site to salvage the reconstruction after failure of the distal perforator‐based anterolateral thigh flap

We presented a patient who experienced the anterolateral thigh (ALT) flap failure but the reconstruction was successfully salvaged by harvesting a second ALT flap from the same donor site 2 days after the first reconstruction. A 47‐year‐old man received cancer ablation for right mouth floor squamous cell carcinoma. The resultant defect was planned to be reconstructed with the ALT flap. During the flap dissection, we identified three proximal cutaneous perforators originating from the transverse branch of the lateral circumflex femoral artery (t‐LCFA) and two distal cutaneous perforators originating from the descending branch (d‐LCFA). We harvested a skin flap based on the distal two perforators and divided the d‐LCFA just distal to the bifurcation of the d‐LCFA and the t‐LCFA. Unfortunately, the ALT flap showed venous congestion on postoperative day 2 and eventually failed. We harvested a second ALT flap from the same donor site based on the previously preserved perforators. The recovery course was smooth thereafter. We believe that the harvest of a second ALT flap from the same donor site may be an option, to avoid other donor site violation, in some patients who experienced the first flap loss. © 2014 Wiley Periodicals, Inc. Microsurgery 34:409–412, 2014.     

Bilateral pedicle anterolateral thigh (ALT) flap combined with bilateral sartorius muscle flap for reconstruction of extensive perineoscrotal and medial thigh defect because of Fournier's gangrene

Fournier's gangrene is an acute and potentially lethal necrotizing fasciitis that can lead to extensive defects of the perineoscrotal area and lower abdominal wall as well. Such defect poses challenging tasks for both functional and cosmetic reconstruction. Local perforator pedicle flaps and muscle flaps can be employed and combined for such a reconstruction. In this report we present a case of reconstruction of a massive perineoscrotal and upper medial thigh defect because of Fournier's gangrene using a bilateral pedicle anterolateral thigh (ALT) flap and sartorius muscle flap. A 61 year‐old male who suffered from Fournier's gangrene resulted in a perineal, scrotal, and medial thigh defect of 27 × 30 cm² with exposure of the femoral vessels. A bilateral pedicle ALT flap measuring 30 × 9 cm² based on two perforators and a bilateral sartorius muscle flap were harvested for soft tissue defect reconstruction and inguinal vessels coverage, respectively. The flaps survived completely, with no recipient or donor site morbidity. The length of follow‐up was 6 months and was uneventful. A bilateral pedicle ALT flap combined with bilateral sartorius flap may be considered as a valid and safe option for an extensive inguinal and perineoscrotal reconstruction in selected cases. © 2016 Wiley Periodicals, Inc. Microsurgery 37:669–673, 2017.     

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 chest wall chondrosarcoma with an anterolateral thigh free flap: An illustration of decision-making in chest wall reconstruction

INTRODUCTIONChondrosarcomas are the most common primary chest wall malignancy. The mainstay of treatment is radical resection, which often requires chest wall reconstruction. This presents numerous challenges and more extensive defects mandate the use of microvascular free flaps. Selecting the most appropriate flap is important to the outcome of the surgery.PRESENTATION OF CASEA 71-year-old male presented with a large chondrocarcoma of the chest wall. The planned resection excluded use of the ipsilateral and contralateral pectoralis major flap because of size and reach limitations. The latissimus dorsi flap was deemed inappropriate on logistical grounds as well as potential vascular compromise. The patient was too thin for reconstruction using an abdominal flap. Therefore, following radical tumour resection, the defect was reconstructed with a methyl methacrylate polypropylene mesh plate for chest wall stability and an anterolateral thigh free flap in a single-stage joint cardiothoracic and plastic surgical procedure. The flap was anastomosed to the contralateral internal mammary vessels as the ipsilateral mammary vessels had been resected.DISCUSSIONThe outcome was complete resection of the tumour, no significant impact on ventilation and acceptable cosmesis.CONCLUSIONThis case demonstrates the complex decision making process required in chest wall reconstruction and the versatility of the ALT free flap. The ALT free flap ensured adequate skin cover, subsequent bulk, provided an excellent operative position, produced little loss of donor site function, and provided an acceptable cosmetic result.