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.     

Reconstruction of a complex pelvic perineal defect with pedicled anterolateral thigh flap combined with bilateral lotus petal flap: A case report

Reconstructing extensive perineal defects represents a challenge, and reconstructive choice requires a careful physical assessment of previous radiotherapy, pre‐existing scars, the presence of stomas, and the availability of donor sites. We report a case of a patient affected by an anal carcinoma who underwent a pelvic exenteration and bilateral inguinal iliac obturator lymph node dissection. We performed a pedicled anterolateral thigh flap (ALT) combined with bilateral lotus petal flaps (LPF) to reconstruct the pelvic–perineal area. The result was good, and no major post‐operative complications were reported. Bilateral LPF, combined with a pedicled ALT, may represent a valid option in pelvic–perineal reconstruction following a wide oncological resection. © 2014 Wiley Periodicals, Inc. Microsurgery 35:154–157, 2015.     

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.     

Pedicled fasciocutaneous anterolateral thigh flap for the reconstruction of a large postoncologic abdominal wall resection defect: a case report

The anterolateral thigh (ALT) flap has been used to cover defects between the proximal third of the leg and lower abdomen, and with modification, may cover epigastric defects. We used the ALT flap to cover a full-thickness defect of over half the anterior abdominal wall. We conclude that abdominal wall defects of large sizes can be successfully reconstructed using an appropriately designed ALT flap; a simple, single-stage effective reconstruction.     

Proximal pedicled anterolateral thigh flap for reconstruction of trochanteric defect

We describe our experience using the proximal pedicled anterolateral thigh (ALT) flap for the reconstruction of trochanteric defects. Seven ALT island flap procedures were performed in 6 patients between September 2006 and May 2007. Four of the 7 patients had trochanteric pressure sores because of paraplegia. In these patients, intramuscular perforators were dissected to raise a fasciocutaneous flap. Three myocutaneous flaps of the vastus lateralis muscle were used to treat osteomyelitis of the trochanter with implant extrusion. The mean follow-up was 7 months (range, 2-12 months), and all flaps survived. Trochanteric coverage with the proximal pedicled ALT flap gave excellent results. We conclude that the ALT flap is a reliable flap for trochanteric coverage.     

Uterine liposarcoma invading abdominal wall and inguinal region. Immediate reconstruction using a pedicled anterolateral thigh flap

The anterolateral thigh flap is a particular flap of the vastus lateralis musculocutaneous flap (perforator flap). This flap was used as a pedicled flap to reconstruct the abdominal wall and to cover the inguinal region following the resection of a voluminous tumor of the womb invading the abdominal wall, the femoral vessels and the skin. The flap included a large facial paddle nourishing a skin island and a little muscle paddle including the perforator vessel. This medially positioned facial paddle allowed to increase the area of useful flap. So it was possible to reconstruct a 10x15 cm abdominal wall defect, and to cover the vascular decking in inguinal region with this only flap. In spite of the harvesting of a small muscular paddle of vastus lateralis (with conservation of the motor nerve) the function of thigh extension has been preserved. Besides the subtlety described to increase the "solid" surface of the fragment, it seems that the anterolateral thigh flap is perfectly useful to cover defects of soft tissues in inguinal region after vascular surgery, indication which was not reported to our knowledge in spite of the high frequency of these losses defects.     

Abdominal wall reconstruction using anterolateral thigh flap with microsurgical pedicle lengthening technique: A case report

Pedicled anterolateral thigh (ALT) flap has been employed for coverage of low abdominal wall defects. However, its use is limited for defects located more on the cranial side because of insufficient pedicle length. We present a case of successful reconstruction of mid-abdominal wall defect using pedicled ALT flap, overcoming the issue of pedicle length shortage with a microsurgical pedicle lengthening technique. A 75-year-old man suffered from a 12 × 8 cm full-thickness soft tissue defect on his mid-abdominal wall originated from colon anastomosis site leakage after ileostomy takedown surgery. A pedicled ALT flap was planned for the defect coverage. After we performed debridement to prepare the wound bed, a 14 × 8.5 cm sized ALT flap based on two lateral circumflex femoral artery (LCFA) perforators was elevated. During intramuscular dissection of perforators, we dissected the distal portion of the LCFA descending branch. After full dissection of the pedicle to source vessels, we attempted to transfer the flap, but still the flap had short pedicle. We transected the pedicle just distal to the bifurcating point and reconnected it to the distal end of the dissected descending LCFA branch with microsurgical anastomosis. We passed the flap through a subcutaneous tunnel and conducted smooth flap insetting without any tension on the lengthened pedicle. Postoperatively, the wound healed successfully without complications. The patient was discharged 2 weeks after surgery and followed up at postoperative 3 months without adverse events. A local ALT flap with pedicle lengthened might be a reliable option for reconstruction of supraumbilical abdominal defects.     

Reconstruction of a large chest wall defect with a musculocutaneous free flap using anterolateral thigh musculature

Reconstruction of a large postmastectomy irradiated chest wall defect was accomplished with a large musculocutaneous free flap of anterolateral thigh musculature and skin. The vascular anatomy of the donor area allows a very substantial flap and skin island to be transferred, leaving a well-tolerated donor defect.     

Reconstruction of an extensive thigh defect with the paraumbilical TRAM flap

Reconstruction of extensive defects after radical resection of soft-tissue sarcomas of the extremities has become an essential part of the limb salvage approach to the management of these tumors. The authors describe the successful use of a paraumbilical transverse rectus abdominis musculocutaneous flap with the pedicle based on the inferior epigastric artery for reconstruction of a 24- x 22-cm soft-tissue and skin defect of the anterior thigh after wide local excision of a recurrent malignant fibrous histiocytoma. The ability to mobilize a large amount of well-vascularized soft tissue from an acceptable donor site, the versatility of flap design, the extensive arc of rotation, and the dependability of the inferior epigastric vascular pedicle are all distinct advantages of using this flap in the reconstruction of massive defects of the thigh.     

A modification of technique to cover a large posterior thigh defect using an anterolateral thigh flap

Anterolateral thigh (ALT) flap is one of the popular flaps for soft-tissue reconstruction. It is a versatile flap which commonly used to resurface external skin defect and internal mucosal lining. In addition if raised as musculocutaneous flap, the muscle portion provides bulk to fill up any potential space. With increase knowledge on the vascular anatomy of this flap, it is possible to harvest 2 skin paddles base on more than one branches of the supplying vessel. This technique is commonly employed to provide coverage of more than one epithelial surfaces such as the complex facial defect after maxillectomy where both the cheek skin and oral mucosa reconstruction are required. Using similar concept, we report a case in which a large external skin defect was successfully covered with an ALT flap and the donor site could be closed primarily without skin grafting.     

Supercharged reverse pedicle anterolateral thigh flap in reconstruction of a massive defect: A case report

Secondary reconstruction of lower extremity defects using local tissues is demanding and fraught with potential complications. Reconstructive efforts may be challenged by pre‐existing scarring, paucity of recipient vessels, and patient co‐morbidities limiting tolerance for prolonged and extensive surgery. We present a case of an 81‐year‐old male with a recurrent malignant melanoma invading the proximal and middle third of the tibia, who previously underwent reconstruction with the medial gastrocnemius muscle and a skin graft. After wide local re‐excision and tibia fixation, a 12 cm × 28 cm reverse anterolateral thigh flap was used for soft tissue coverage. Because of the relatively large size of the flap based upon retrograde flow, we elected to supercharge the flap to augment its blood supply. Supercharging of the flap pedicle was accomplished by anastamosing the lateral circumflex femoral vessels to the anterior tibial vessels. The donor site wasclosed primarily. The flap survived entirely and successfully endured subsequent radiation therapy. Supercharging enhances reliability of the reverse anterolateral thigh flap, and thus, permits harvest of large tissue bulk for coverage of up to proximal two‐thirds of the tibia.This is the first report describing successful supercharging of a large reverse anterolateral thigh flap which resulted in entire flap survival. © 2010 Wiley‐Liss, Inc. Microsurgery 30:397–400, 2010.     

Turbocharged bilateral pedicled DIEP flap for reconstruction of thigh defect without recipient vessels: A case report

Reconstruction of thigh defects is usually straightforward, but in cases of poor soft tissue quality, free flap reconstruction is not possible due to the absence of recipient vessels. The turbocharge technique may increase the viable, vascularized area of a flap. In this report we present a case of the use of a turbocharged bilateral pedicled DIEP flap for reconstruction of thigh defect without recipient vessels. A 29‐year‐old woman who underwent neoadjuvant chemotherapy plus radiation therapy for a leiomyosarcoma on the left thigh. Six weeks later, complete tumor excision and a femoropopliteal bypass with contralateral saphenous vein was performed. In the following days the wound had dehiscence, infection, necrosis of the surrounding muscles and exposure of femoropopliteal bypass. No recipient vessels were available for free flap and critical limb ischemia due to bypass thrombosis was detected. The reconstruction of a large thigh defect (30 × 12 cm) and the coverage of a femoropopliteal bypass with a turbocharged bilateral pedicled DIEP flap was performed. A flap including the entire infraumbilical tissue was designed and the anastomosis of the proximal stump of the right inferior epigastric vessels with the distal ends of the inferior left epigastric vessels was performed to increase the viable area. The flap survived without any complications during the postoperative period. At 12‐month follow up, coverage was stable with no tumor recurrence. Our result suggests that a turbocharged bilateral pedicled DIEP flap may be an option for reconstructing large tissue defects when no recipient vessels are available for free flap.     

Reconstruction of a large full‐thickness abdominal wall defect with flow‐through‐based alt flaps: A case report

An extensive 35 × 20 cm sized full‐thickness abdominal wall defect was created after resection of aggressive abdominal fibromatosis in a 19‐year‐old male patient. Immediate reconstruction was not possible due to prolonged operation time and resulting severe bowel edema. A silicone sheet with NPWT was applied over the exposed viscera. After 1 week, silicone sheet was substituted with a composite mesh. Then, abdominal wall reconstruction with bilateral free anterolateral thigh (ALT) flaps (30 × 12 cm and 25 × 12 cm sized) was performed. Since there was only a single reliable recipient vessel available, we linked 2 ALT free flaps sequentially in a flow‐through fashion to the left inferior epigastric artery and vein. Two donor sites were closed primarily. The flap fully survived and the defect was covered successfully without any complication for 11 months of follow up. Multiple flaps may be needed for large full‐thickness abdominal wall defect coverage. Linked fasciocutaneous free flaps could be a solution with a less donor site morbidity even in the case of limited available recipient vessels. The purpose of this study is to introduce our experience of extensive full‐thickness abdominal wall reconstruction using only ipsilateral deep inferior epigastric vessels.