Versatility of the pedicled anterolateral thigh flap

The Pedicled Anterolateral Thigh Flap as a Versatile Option for Resurfacing Extensive Lower Trunk Defects

BACKGROUND

The resurfacing of large abdominal and perineal defects is a major concern, and it poses a great challenge to the reconstructive surgeon. The main target in the reconstruction of the abdomen is to ensure a stable soft-tissue cover, and a strong and reliable fascia to prevent hernia recurrence and fecal contamination. The pedicled anterolateral thigh flap (ALT) either in the myocutaneous or fasciocutaneous form is a work-horse for the closure of abdominal and perineal defects.

AIM

There is a paucity of studies on the use of the anterolateral thigh flap among black Africans especially in Nigeria; hence, we present our experience with the use of this flap for extensive abdominal and perineal defects.

PATIENTS AND METHODS

The folders of all patients who had pedicled anterolateral thigh flap between January 2019 and July 2022 in our institution were reviewed. The patients' demographic data and the available details about the flap reconstruction were extracted from the folders.

RESULTS

There were three males and two females, and the age range was between 22 and 48 years. Four cases resulted from tumor extirpation, while one was following extensive necrotizing fasciitis of the lower anterior abdominal wall. No gross anatomical variations were encountered intraoperatively. Four flaps had full survival, while one had marginal flap tip loss.

CONCLUSION

The pedicled anterolateral thigh flap is an excellent reconstructive tool for the coverage of extensive abdominal and perineal defects.

Pedicled anterolateral thigh flap: A versatile flap for complex regional defect reconstruction

Objectives

Soft-tissue defects of the lower abdomen, perineum, groin, and trochanteric area often involve the loss of composite tissue components and are technically challenging to reconstruct. The goals of reconstruction should include the replacement of the defect with a suitable soft-tissue flap that provides stable coverage while protecting important exposed structures. However, there are limited locations in this region for the creation of pedicled flaps for complex defect reconstruction. The pedicled anterolateral thigh (ALT) flap is considered superior to other comparable flaps due to its varying soft-tissue components and long pedicle with consistent anatomy that allow the reconstruction of locations that are difficult to reach without significant flap donor site morbidity. Herein, we present a case series of our experience of using a pedicled ALT flap to reconstruct regional defects over a range of locations.

Methods

The present study comprised ten patients who underwent surgical reconstruction of soft-tissue defects of the lower abdomen, groin, trochanteric, scrotal, and penoscrotal defects using a pedicled ALT flap over a two-year period. The flap was customized according to the defect when required.

Results

In our case series, flap loss was not observed with only a few minor complications. All patients accepted the aesthetic appearance of the flap recipient site area without requesting revision surgery. The donor site was closed primarily in half of all cases, with split skin grafting applied in the remaining patients. Graft take at the flap donor site was satisfactory in all cases.

Conclusion

A pedicled ALT flap is a reliable and suitable option for complex soft-tissue reconstruction for regional soft-tissue defects of the lower abdomen and perineum.

"Extensive necrosis following extravasation of alkali in the crease of the elbow after voluntary intravenous injection: A case report"

Chemical burns are often deep with difficult initial clinical evaluation, especially those due to alkalic agents, which have a strong penetrating power. They therefore require specialized care in a Burn Unit. Self-inflicted burns are infrequent but their management represents a real challenge. We report the case of a 47-year-old referred to our Burn Center for the evaluation of a self-inflicted corrosion with an alkalic agent (soda), injected at the crease of the left elbow. The patient, right handed, was a nurse and had notably a psychiatric history of depressive syndrome. We observed a deep, well-defined necrosis area, associated with intense peri-lesional inflammation and extensive cellulitis. Faced with this unusual clinical appearance for a chemical burn, the patient's questioning was repeated and the patient finally admitted to having injected himself with a basic caustic product intravenously. Surgical treatment was carried out in two stages: debridement with exposure of vascular and neural structures then coverage with a free anterolateral thigh flap. The postoperative consequences were uneventful with a satisfactory functional result. Factitious disorders are underestimated and often misleading. Among factitious disorders, self-inflicted wounds remain a real challenge requiring multidisciplinary management. Many etiologies exist, among which injection of drugs or substances, in any anatomical localization, leading to variable loss of substance. The use of a free flap for acute extravasation is rare but sometimes essential. The anterolateral thigh flap allows good resurfacing on areas with important functional requirements.

Challenges in the Management of Kidney Allograft Herniation With a Single-stage Pedicled Anterolateral Thigh Flap

Wound complications are the most common surgical complication after kidney allograft transplantation. Total wound rupture exposing the entire kidney is a rare and not well-described event. We present a successful treatment of this complication in a patient admitted to our unit. A single-stage procedure was performed combining debridement and reconstruction with a pedicled anterolateral thigh flap and an iliotibial band transferring. A short literature review is performed comparing the different treatment strategies and results.

Abdominal Wall Reconstruction Using Pedicled Antero Lateral Thigh Flap

Background

Reconstructing abdominal wall defects has been a difficult task for surgeons. The abdominal wall defects range from defects of only soft tissue to full thickness defects including all the three layers of the abdomen. Only soft tissue defects are commonly caused by peritonitis and laparotomies, and full thickness defects can occur from en bloc resection of tumours as well as trauma. Treatment options available include component separation, partition technique, flap coverage, and more recently acellular dermal matrix.

Methods

This retrospective study done between 2016 and 2020 where 20 patients were operated for abdominal wall defect using Pedicled ALT flap in the Department of Plastic and Reconstructive Surgery, Sawai Man Singh Hospital, Jaipur, Rajasthan, India.

Results

The study consisted of total 20 patients, 14 males and 6 females. Eight patients were post electric burn, 5 patients had suffered trauma, 4 patients underwent resection of abdominal wall tumour and 3 patients were post laparotomy for peritonitis. Mean age of patients was 48 years (range from 36 to 62 years). Mean fascia defect size was 14.2 cm (range 12.2 to 16.4 cm). Mean operative time was 170 minutes (range from 140 minutes to 220 minutes). Postoperative hospital stay ranged from 8 days to 24 days (mean- 12 days).

Conclusion

Pedicled ALT flap has expanded the armamentarium of plastic surgeons for reconstruction of abdominal wall defects.

Free Your Mind, Not Your Flap

The pedicled flap has been a mainstay of soft tissue reconstruction since the earliest days of plastic surgery. Advances in surgical technology and skill have led to an erosion in the use of pedicled flaps in favor of increasingly popular free tissue transfers. Still, regional flaps without microvascular anastomosis remain a valuable reconstructive tool. Although still requiring microsurgical skills, these flaps are of particular benefit in patients with few or poor quality recipient vessels, in those who cannot tolerate antiplatelet therapy, and in those who cannot tolerate the often-extended anesthesia time necessitated by microvascular anastomosis. Furthermore, pedicled flaps may significantly reduce total cost of a reconstruction procedure with similar outcomes. In this case series, we report challenging scenarios where microsurgical approaches may have been typical choices but were instead reconstructed by pedicled options with desired outcomes. Difficult soft tissue defects were successfully reconstructed with a variety of pedicled flaps. Soft tissue transfers to the abdomen, flank, shoulder, and back are presented. None of the reconstructions required microvascular anastomosis.

Versatility of the lateral circumflex femoral artery sparing perforator-based anterolateral thigh flaps in loco-regional thigh reconstruction after skin cancer, melanoma, and sarcoma resection

BACKGROUND

The anterolateral thigh (ALT) flap represents a workhorse in reconstructive microsurgery but its use in a free style fashion as perforator-based flap has yet to be popularized. We describe our experience with lateral circumflex femoral artery (LCFA) sparing perforator-based ALT flaps for thigh reconstruction after oncological resection in a case series of 24 consecutive patients.

METHODS

Twenty-four patients underwent thigh reconstruction with 25 perforator-based ALT flaps between 2014 and 2020. Defect etiology was related to skin cancer, melanoma, and sarcoma resection in 3, 7, and 14 cases respectively. Mean defect size was 15 × 8 cm. Six months postoperatively, patients were asked to rate on a 5-point Likert scale the aesthetic and functional outcomes of the reconstructive procedure.

RESULTS

Eight flaps were advanced in a V-Y fashion (33.3%), whether 16 flaps (66.7%) were rotated in a propeller fashion. The average flap size was 19 × 8 cm, while mean operative time was 197.2 min. Donor sites were always closed by primary intention. Minor complications were registered in 5 cases and managed conservatively. Overall patients' satisfaction was high, with mean aesthetic and functional ratings of 4.46 and 4.21 respectively.

CONCLUSIONS

LCFA sparing perforator-based ALT flaps proved to be a versatile and reproducible solution to address thigh reconstruction after oncological resection according to the different topographical sub-units involved.

Individually Tailored Approach to Reconstruction of Complex Defects Using Versatility of the Lateral Circumflex Femoral Artery System-Based Pedicled Flaps

Lateral circumflex femoral artery (LCFA) system is one of the most versatile donor sites in the body. We present our experience with pedicled flaps from the LCFA system, including different components for a wide variety of etiologies and locations. Twenty-three consecutive pedicled flaps were performed on 22 patients (10 females and 12 males; age 4-71 years) between 2007 and 2015 by a single surgeon. Flap size, type, and composition were tailored according to the requirements of the defects, including (1) location; (2) surface area; (3) depth; (4) number of defects; (5) presence of exposed critical structures; (6) presence of exposed foreign bodies; (7) prior use of other options; (8) history of radiation; and (9) other comorbidities. Defect locations were 10 abdominal wall (including groin and pubis), 9 ischio-gluteo-trochanteric and 4 perineal. Defect sizes ranged from 6 × 6 to 30 × 35 cm. Maximum depth of wounds ranged between 7 and 18 cm. The flap sizes ranged from 9 × 6 to 38 × 20 cm. Two flaps were fasciocutaneous perforator, 4 were myocutaneous with "muscle sparing" vastus lateralis, 10 were myocutaneous with "segmental" vastus lateralis, 5 were myocutaneous "tri-muscle," 1 was "tri-muscle," and 1 was rectus femoris only. Donor sites were closed primarily in 20 cases and with split thickness skin grafting in 3 cases. All flaps survived completely without any partial loss or congestion. Pedicled flaps from the LCFA system can be tailored individually for a wide variety of etiologies and locations. Muscles can be harvested and used as "muscle sparing," "segmental," and "tri-muscle" to accommodate the requirements of the defects.

Defect Reconstruction Using the Propeller Flaps Based on the Perforators Derived From the Lateral Circumflex Femoral Artery System

BACKGROUND

Although propeller flaps are a useful option for soft tissue defect reconstruction, reports based on the perforators of the lateral circumflex femoral artery (LCFA) are rare. We aimed to present our experience in defect reconstruction using the propeller flaps based on perforators from different branches of LCFA and apply these flaps in soft tissue defect reconstruction of the lower extremities.

METHODS

Twenty nine patients (32 flaps) underwent defect reconstruction using propeller flaps based on the perforator of the LCFA. Defects were located from the groin to the proximal leg. According to the source vessels from which the perforator originated, flaps were categorized into types I, II, III and IV, which represented perforators from the transverse, descending, oblique, and rectus femoris branches, respectively. Type II flaps were subdivided into types IIa and IIb flaps based on antegrade and reverse flows of the descending branch.

RESULTS

Flap sizes ranged from 12 × 6 cm to 30 × 15 cm (average, 22.69 × 9.19 cm) with the length of the vascular pedicle ranging from 3 to 7 cm (average, 4.86 cm). Flaps were rotated from 60° to 180° (average, 144.06°). There were 3 type I, 10 type IIa, 4 type IIb, 13 type III and, and 2 type IV flaps. Twenty-nine flaps survived after surgery. Total flap necrosis and venous congestion of the distal flap portion occurred in 1 and 2 patients, respectively.

CONCLUSIONS

Reconstruction using propeller flaps based on perforators of the LCFA is a safe, reliable, and versatile option for defect reconstruction of the lower extremities; however, it requires meticulous surgical dissection and patience.

The pedicled anterolateral thigh flap for trochanteric pressure sore reconstruction: Technical notes to optimize surgical outcomes

Background

The pedicled anterolateral thigh (ALT) flap has become more popular for the reconstruction of soft-tissue defects in neighboring areas. Nonetheless, few studies in the literature have explored the use of this flap for trochanteric ulcer reconstruction. The aim of our study is to present the author’s experience of utilizing the ALT flap, with a focus on technical elements regarding the flap design and the tunneling method to maximize the reach of the flap.

Methods

The medical records of patients who received pedicled ALT flaps for the reconstruction of trochanteric pressure sores were retrospectively reviewed. The patients’ demographic data, operative details, and postoperative complications were evaluated.

Results

Between October 2018 and December 2019, 10 consecutive patients (age range, 13–45 years) underwent 11 pedicled ALT myocutaneous flaps for trochanteric pressure sore reconstruction. Each flap was designed around the most distal cutaneous perforator that was included in the proximal third of the skin paddle. The flaps ranged in size from 11×6 to 14×8 cm. The ALT flap was transposed through a lateral subcutaneous tunnel in five patients, while the open tunnel technique was used in six patients. All flaps survived, and no vascular compromise was observed.

Conclusions

The pedicled ALT flap is a safe and reliable option for reconstructing trochanteric pressure sores. An appropriate flap design and a good choice of the tunneling method are crucial for successful flap transposition.

Maximizing the Utility of the Pedicled Anterolateral Thigh Flap for Locoregional Reconstruction: Technical Pearls and Pitfalls

The pedicled anterolateral thigh (PALT) flap is an underutilized flap for locoregional reconstruction largely because methods to maximize its reach are neither universally implemented nor fully understood. In addition, most of the available literature has focused on the utility of the free anterolateral thigh flap with less emphasis on the PALT flap. Moreover, flap design concepts to maximize its utility and reach and optimize outcomes have not been comprehensively described. In an effort to address this knowledge gap, the authors sought to review their institution's experience with the PALT flap for locoregional reconstruction.

Surgical treatment of massive stoma site tumors after a curative operation for rectal cancer

OBJECTIVE

This study aimed to evaluate the clinical and oncological outcomes of selected rectal cancer patients with massive stoma site tumors who underwent radical resection and reconstruction.

METHODS

We reviewed 8 cases of massive stoma site tumors in patients who had permanent gastrointestinal stoma in the abdominal wall following radical resection of rectal cancer between March 2013 and May 2018 at the Peking University Cancer Hospital and Peking University Shougang Hospital.

RESULTS

There were seven males and one female patient, with a median age of 50.6 years. The average time between the initial surgery and the development of a malignant tumor at the stoma site was 5 years (range, 0.5-14 years). The average diameter of the stoma site tumors was 8.1 cm, and the diameter of the largest tumor was 12 cm. After tumor resection, the area of the largest abdominal wall defect was about 15 × 14 cm². Abdominal wall repair included the use of a tensor fasciae latae muscle flap, local fasciocutaneous rotational flap, and pedicled anterolateral thigh flap. No patient died in the 30 days following surgery. The longest follow-up period was 81 months, and 5 patients died.

CONCLUSIONS

Multidisciplinary clinical management fosters positive outcomes in treating massive stoma site tumors. Local R0 resection and abdominal wall reconstruction are safe and feasible, and function to removes local disease, allowing patients to live a higher quality of life.

Versatility of the pedicled anterolateral thigh flap for surgical reconstruction, a case series

Background

The pedicled anterolateral thigh flap is a versatile flap that offers many advantages. These include a long and reliable pedicle that enables a wide arch of rotation, the possibility to harvest a large skin area, raising the flap with underlying fascia and muscle and minimal donor site morbidity.

Methods

From 2009 to 2018 nine patients were reconstructed with a pedicled anterolateral thigh flap. The flap was applied for coverage of knee infections, trochanteric defects, an abdominal defect, a gluteal defect, and a defect of the inguinal region. The patient group consisted of five males and four females. The age range was 30–90 years with a mean age of 61 years.

Results

Flap size ranged from 10 x 5 cm (50 cm²) to 15 x 30 cm (450 cm²) with a mean size of 222 cm². We experienced no flap loss. The donor site was closed directly in seven out of nine patients, and the remaining two patients were closed by split-thickness skin grafting. Satisfactory aesthetic and functional outcome was achieved in all patients.

Conclusion

Our experience illustrates the versatility in the clinical application of the pedicled anterolateral thigh flap. The many advantages of the flap, such as the long and reliable pedicle, a large area of skin that can be harvested, the potential to supercharge the flap and the minimal donor site morbidity highlights the diversity of defects that can be reconstructed using this flap.

Pelvic/Perineal Reconstruction: Time to Consider the Anterolateral Thigh Flap as a First-line Option?

Background:

Abdominoperineal resection (APR) and pelvic exenteration continue to be common procedures for the treatment of colorectal malignancy. The workhorse flap for reconstruction in these instances has been the vertical rectus abdominis myocutaneous flap. The associated donor site morbidity, however, cannot be ignored. Here, we provide a review of the literature and present the senior author’s (A.M.) experience using the pedicled anterolateral thigh (ALT) flap for reconstruction of soft tissue defects following APR and pelvic exenteration.

Methods:

Patients who underwent pelvic/perineal reconstruction with pedicled ALT flaps between 2017 and 2019 were included in the study. Parameters of interest included age, gender, body mass index, comorbidities, history of radiation, extent of ablative surgery, and postoperative complication rate.

Results:

A total of 23 patients (16 men and 7 women) with a median age and body mass index of 66 years (inter-quartile range [IQR]: 49–71 years) and 24.9 kg/m² (IQR: 24.2–26.7 kg/m²) were included in the study, respectively. Thirteen (56.5%) patients presented with rectal cancer, 5 (21.7%) with anal squamous cell carcinoma (SCC), 4 (17.4%) with Crohn’s disease, and 1 (4.3%) with Paget’s disease. Nineteen patients (82.6%) received neoadjuvant radiation. Nine (39.1%) patients experienced 11 complications (2 major and 9 minor). The most common complication was partial perineal wound dehiscence (N = 6 [26.1%]). Stable soft tissue coverage was achieved in all but one patient.

Conclusions:

The ALT flap allows for stable soft tissue coverage following APR and pelvic exenteration without being associated with abdominal donor site morbidity. Consideration to its use as a first-line reconstructive option should be given in pelvic/perineal reconstruction.

Maximizing the Utility of the Pedicled Anterolateral Thigh Flap for Locoregional Reconstruction: Technical Pearls and Pitfalls

The pedicled anterolateral thigh (PALT) flap is an underutilized flap for locoregional reconstruction largely because methods to maximize its reach are neither universally implemented nor fully understood. In addition, most of the available literature has focused on the utility of the free anterolateral thigh flap with less emphasis on the PALT flap. Moreover, flap design concepts to maximize its utility and reach and optimize outcomes have not been comprehensively described. In an effort to address this knowledge gap, the authors sought to review their institution's experience with the PALT flap for locoregional reconstruction.

Abdominal- versus thigh-based reconstruction of perineal defects in patients with cancer

BACKGROUND

An abdominoperineal resection is an invasive procedure that leaves the patient with vast pelvic dead space. Traditionally, the vertical rectus abdominus myocutaneous flap is used to reconstruct these defects. Oftentimes, this flap cannot be used because of multiple ostomy placements or previous abdominal surgery. The anterolateral thigh flap can be used; however, the efficacy of this flap has been questioned.

OBJECTIVE

We report a single surgeon's experience with perineal reconstruction in patients with cancer with the use of either the vertical rectus abdominus myocutaneous flap or the anterolateral thigh flap to demonstrate acceptable outcomes with either repair modality.

DESIGN

From 2010 to 2012, 19 consecutive patients with perineal defects secondary to cancer underwent flap reconstruction. A retrospective chart review of prospectively entered data was conducted to determine the frequency of short-term and long-term complications.

SETTINGS

This study was conducted at an academic, tertiary-care cancer center.

PATIENTS

Patients in the study were patients with cancer who were receiving perineal reconstruction.

INTERVENTIONS

Interventions were surgical and included either abdomen- or thigh-based reconstruction.

MAIN OUTCOME MEASURES

The main outcome measures included infection, flap failure, length of stay, and time to radiotherapy.

RESULTS

Of the 19 patients included in our study, 10 underwent anterolateral thigh flaps and 9 underwent vertical rectus abdominus myocutaneous flaps for reconstruction. There were no significant differences in demographics between groups (p > 0.05). Surgical outcomes and complications demonstrated no significant differences in the rate of infection, hematoma, bleeding, or necrosis. The mean length of stay after reconstruction was 9.7 ± 3.4 days (± SD) in the anterolateral thigh flap group and 13.4 ± 7.7 days in the vertical rectus abdominus myocutaneous flap group (p > 0.05).

LIMITATIONS

The limitations of this study include a relatively small sample size and retrospective evaluation.

CONCLUSION

This study suggests that the anterolateral thigh flap is an acceptable alternative to the vertical rectus abdominus myocutaneous flap for perineal reconstruction (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A134).

Trans-vastus Intermedius Transfer of the Pedicled Anterolateral Thigh Flap for Posterior Thigh Reconstruction

SUMMARY

Proximal, posterior thigh wounds from oncologic or traumatic defects can be difficult wounds to reconstruct if local flap options have been sacrificed during the trauma or oncologic resection. Free flap options to cover these defects are also difficult because of the lack of convenient recipient vessels in the region. The authors present 2 cases (oncologic and traumatic) wherein a myocutaneous anterolateral thigh (ALT) flap was harvested and tunneled from the anterior muscle compartment to the posterior muscle compartment of the thigh through a medially based transmuscular tunnel, decreasing the required pedicle distance to the wound. This technique of transmuscular tunneling of the ALT flap expands the indications and utility of the ALT flap to cover posterior thigh wounds.

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.

Scrotal and perineal reconstruction

The scrotal and perineal area serves a special function. It is the pelvic outlet for the gastrointestinal tract, urinary system, and sexual function. In the male, the scrotum allows testicular mobility to reduce trauma and allow optimal thermal regulation for spermatogenesis. Trauma, infection, and cancer resection create defects that require reconstruction. The reconstructive goal here is to obtain durable coverage, function, and lastly aesthetic outcome. Pedicled local and regional flaps are the mainstay for this area. Due to the special function and appearance of the scrotum, reconstructive options for total scrotal defect always fall far short of the native scrotum. On the other hand, perineal reconstruction is overall satisfactory.