Split-skin Paddle Anterolateral Thigh Flap for Reconstruction of Giant Dermatofibrosarcoma Protuberans in Groin

Split Anterolateral Thigh Flap: A New Classification of Anatomical Variants and a Surgical Planning Algorithm

BACKGROUND

 Split anterolateral thigh flap is a versatile reconstruction option, yet long underestimated as no practical perforator classification and no optimal strategy were present. Harvesting "capillary nonsizable perforators" could potentially expand flap splits to those with no existing multiple sizable perforators. Concerns over defect characteristics, recipient vessels, pedicle length, and split timing should all be weighted equally in designing the suitable flap. Refinement is thus required to enable precise reconstructions.

METHODS

 All patients undergoing anterolateral thigh flap harvests between 2014 and 2021 performed by a single surgeon were included. The perforator patterns of sizable pedicle, course, origin, and further successful flap-split methods were documented. Surgical outcome of flap survival was analyzed.

RESULTS

 Anatomical variants of 134 (48.4%) dual, 123 (44.4%) single, and 20 (7.2%) no sizable perforators were found in a total of 277 anterolateral thigh flaps. The overall flap survival rate was 97.5%. Flap split was performed in 82 flaps, including 29 single and 5 no sizable perforator cases previously considered "unsplittable," by utilizing a series of direct skin paddle split, capillary nonsizable perforators harvesting, and flow-through anastomosis technique. Comparable flap survivals were found between split and nonsplit flaps as well as between split segments supplied by sizable and capillary nonsizable perforators. Primary closure was achieved in 98.9% of the thigh donor sites.

CONCLUSION

 A new classification of the common anterolateral thigh flap anatomical variants was proposed and a comprehensive algorithm of split flap strategy was developed along with the innovative "fabricate" concept.

Intraoperative salvaging of failure to harvest the bi-paddle anterolateral thigh flap: a case series

Background

The size and versatility of anterolateral thigh (ALT) flap enables a bi-paddle flap to cover complex and extensive defects optimally. However, it is characterized by variations in the sources of blood vessels and in the number of perforators, which increases the chances of failure of harvesting a bi-paddle flap. We present our method to overcome such failure. This is the first study exploring the optimal salvaging algorithm to overcome harvesting failure with the bi-paddle ALT flap.

Methods

From January 2014 to December 2020, in 9 patients to be treated with bi-paddle ALT flap for soft-tissue defects (range, 48–288 cm²), there was failure of flap harvest because of perforator variations. We redesigned and converted the flaps to other forms for harvest intraoperatively, based on the characteristics of the defect, and the number and sources of perforators.

Results

Salvage of flap harvest was successfully performed in all 9 cases. In 4 cases the flap with a single perforator was converted to widened-single-perforator flaps; in 2 cases, a single perforator was converted to a de-epithelialized flap; in 2 cases of 2 perforators from different main branches, conversion was to sequential chimeric flaps; in the remaining case of 2 perforators from the descending branch and transverse branch, conversion was to a combined transverse-and-descending branches flap. Venous compromise occurred in only 1 case, and the patient survived after revised surgery. Local infection in the receiving area occurred in 3 cases, and was cured by wound dressing. All flaps survived (follow-up 5–24 months).

Conclusions

Despite preoperative preparation, anatomic variations resulted in failure of bi-paddle ALT flap harvesting. As shown by our results, it is feasible to redesign and convert the bi-paddle flap to other forms based on the defect characteristics, and the number and sources of perforators.