Peripheral Pruning: A Safe Approach to Thinning Extra-Large Anterolateral Thigh Flaps

Thin and Thinned Anterolateral Thigh Flaps for Upper Extremity Reconstruction

Upper extremity reconstruction remains challenging due to the high functional and esthetic demands of this location. The anterolateral thigh (ALT) flap is a workhorse flap for microsurgical reconstruction of the upper extremity and can be elevated in various planes depending on desired thickness of the flap. Microsurgical reconstruction of the upper extremity often benefits from a thin flap that can resurface the extremity, which can provide improved functional and esthetic outcomes. This article reviews the anatomy, preoperative planning, and operative technique, as well as presents 4 cases to illustrate the outcomes and benefits of thin and thinned ALT flaps.

Using Free Chimeric Anterolateral Thigh Flap For Reconstruction Of Composite Dorsal Hand Defect

Background

Simultaneous repair of the extensor tendons and soft tissues in hand injuries remains challenging. The free chimeric anterolateral thigh (ALT) flap with fascia lata (FL) flap represents an alternative for hand reconstruction. This report describes the reconstruction of the extensor tendon and skin defects using free chimeric ALT flaps with FL.

Methods

Eight patients (one female and seven male) underwent reconstruction of complex hand defects with free chimeric ALT and FL flaps. The defects were caused by crushing injuries, burns, snakebite scars, and animal bite wounds. The average skin defect was 116 cm2. Perforators were selected for the skin paddle and the FL flap. The thinning procedure was performed microsurgically.

Results

The skin paddle size ranged from 12 to 23 cm in length and 6 to 11 cm in width, and the FL flaps ranged from 3 × 5 to 12 × 5 cm. The mean pedicle length was 7.88 cm. Nine extensor tendons were repaired with FL flaps. The flap thickness after thinning was only 3-6 mm. The donor site was closed primarily in six patients, and skin grafts were used in two cases. All flaps survived without complications. The follow-up period lasted from 17 to 80 months. Range of motion was achieved with satisfaction.

Conclusion

The chimeric-thinned ALT and FL flap is a valuable material, and it should be considered a reconstructive option for hand soft tissue and extensor tendon reconstruction. This technique allows us to achieve a good appearance and extensor function without donor-site morbidity.

Reconstruction of Finger Soft Tissue Defects With a Thinned Free Anterolateral Thigh Flap

BACKGROUND

Reconstructing complex soft tissue defects of the finger requires both functional and aesthetic aspects. There are many free tissue transfers as suitable options for digital resurfacing. The anterolateral thigh (ALT) flap is not the first choice for reconstruction of this area because it has the disadvantage that the subcutaneous tissue is too thick; however, its use as a thinned form has yet to be described much. This study presents the flap thinning technique in the small-sized ALT flap for the finger soft tissue defect.

METHOD

From May 2009 to March 2018, 10 patients with complete circumferential or semicircumcision defects in the fingers underwent reconstructive procedures that included thinned ALT flap transfer. Finger soft tissue damage due to contusion trauma includes loss of skin and exposure of the bone and tendon. The flap is thinned in 2 different ways: peripheral thinning and total microsurgical thinning, which is selected based on the perforator vessel structure of the flap.

RESULT

The ALT flap sizes, averaging 4-9 cm wide and 6-12 cm long, were thinned to 4-7 mm. One perforator was included in the flaps with a pedicle length average of 6.1 cm. The flaps survived entirely in all patients except one with a 30% area in the distal part of the thinned ALT flap that became necrotic because of venous occlusion. Donor sites were closed primarily for all patients. No patients required secondary flap defatting.

CONCLUSIONS

The small thinned ALT perforator flap can be an excellent option for full circumferential or semicircumferential soft tissue defects of the finger. Follow-up showed this as an excellent alternative for finger reconstruction in terms of aesthetic appearance and functional outcome.

Does leg dominance influence anterolateral thigh flap perforators?

INTRODUCTION

Thorough knowledge of perforator anatomy can facilitate anterolateral thigh (ALT) free flap harvest. The selection of the right or left thigh as donor area may be supported by preoperative perforator imaging and practical considerations. The study aims to determine if the leg dominance should be taken into account, when choosing the donor thigh for ALT free flap harvest, as muscle mass and perfusion might influence perforator quantity.

METHODS

ALT perforators were localized by color-coded duplex sonography and dynamic infrared thermography on both thighs within a defined 250 × 80 mm area in 24 subjects. Perforator number and thickness of subcutaneous tissue and muscle layer were compared in dominant and nondominant legs.

RESULTS

We found no statistically significant difference comparing sonographically identified ALT perforator numbers and hot spot numbers in dominant and nondominant legs. Yet, we found high interindividual differences. The comparison of subcutaneous tissue and muscle thickness yielded no significant difference.

CONCLUSIONS

Our study yielded no evidence for preference of the dominant or nondominant leg in ALT free flap harvesting. As we found high interindividual differences in perforator number, we suggest to rely on preoperative perforator imaging when choosing the ALT free flap donor thigh.

Anterolateral thigh flap for upper extremity reconstruction in older patients

BACKGROUND

The anterolateral thigh (ALT) flap has been used in upper extremity reconstruction. However, there is no consensus about the age at which the flap can be used safely, which is a concern when applying ALT flaps for upper extremity reconstruction in older patients. We present the results of the use of ALT flap for upper extremity reconstruction in a series of older patients.

PATIENTS AND METHODS

Seventeen patients who underwent ALT flaps for soft tissue defects in the upper extremities from 2010 to 2020 were included. The patients' mean age was 63.5 (range, 26-83) years. Ten of seventeen patients were smokers. Defect locations were the dorsum of the hand in seven patients, palm in two patients, dorsum and palm in two patients, and forearm in six patients. Etiologies of the defect were traumatic in 14 patients and malignant tumor in three patients. The defect size was 8 to 25 × 5 to 11 cm. When dissecting the perforators, we preserved the surrounding small muscular and fatty tissue with the perforators and to harvest them together to prevent intima damage. Flap thinning was performed for 16 flaps to adjust the flap thickness to match defect site requirements. We used an end-to-side or interposition arterial anastomosis to regulate the blood flow.

RESULTS

The flap size was 9 to 28 × 5 to 13 cm. One patient had venous congestion and vein re-anastomosis was needed. All flaps survived. One patient had a methicillin-resistant Staphylococcus aureus infection and debridement and irrigation was needed. The mean follow-up period was 20 (range, 13-37) months. Fifteen patients returned their previous activities. The mean DASH score was 30.6 (range, 3-70).

CONCLUSIONS

Regardless of patient age or smoking status, the ALT flap was a safe and reliable surgical option for soft tissue defect reconstruction of the upper extremity.

Free ALT Perforator Flap in Nonobese Patients: The Recontouring of Soft Tissue Defects Around Foot

BACKGROUND

The anterolateral thigh (ALT) perforator flap is well-described and versatile option for reconstruction of soft tissue defects around foot and ankle. This retrospective review was performed for reconstruction of soft tissue defects around foot with ALT perforator flaps in patients with normal and overweight body mass index (BMI).

METHODS

Between January 2016 and November 2020, ALT flaps were used in 30 patients for foot defects.

RESULTS

Etiologic factors were trauma (18 patients), diabetic foot ulcer (6 patients), tumor (3 patients), infection (2 patients) and burn contracture (1 patient). Mean body mass index (BMI) value was 24.9 ± 4.1 (17-30). Mean flap dimension was 145 ± 86 (40-420) cm². Recipient vessels were anterior tibial artery in 17 patients (56%), posterior tibial artery in 12 patients (40%), reversed flow dorsalis pedis artery in 1 patient (3.3%). In 24 patients (80%), 2 vein anastomoses were done. Debulking were applied in two patients (6.6%). Donor area was grafted in four patients (13.3%). Mean flap score was 1.25 ± 0.5. Mean flap thickness was 10 ± 2 (7-14) mm. Visual Analogue Scale (VAS) score was 7.75 ± 1.04 (6-10). The patients were followed up for a mean of 14 ± 11 (1-30) months.

CONCLUSION

We think that ALT flap is still reliable and precious option because it provides ideal soft tissue reconstruction by means of recontouring of foot in nonobese patients.

Pedicled sural flaps versus free anterolateral thigh flaps in reconstruction of dorsal foot and ankle defects in children: a systematic review

BACKGROUND

This systematic review compared free anterolateral thigh (ALT) flaps versus pedicled distally based sural artery (DBSA) flaps for reconstruction of soft tissue defects of dorsal foot and ankle in children.

METHODS

A systematic literature search was performed to identify cases where an ALT or DBSA was used to reconstruct the dorsal foot in children. A total of 19 articles were included in the systematic review.

RESULTS

Eighty-three patients underwent an ALT reconstruction and 138 patients underwent a DBSA reconstruction. Patients who had a DBSA were more likely to require grafting of the donor site (P<0.001). The size of ALT flaps was significantly larger than DBSA flaps (P=0.002). Subsequent flap thinning was required in 30% of patients after ALT and 12% of patients after DBSA reconstruction (P<0.001). Complications occurred in 11.6% of DBSA and 8.4% of ALT flaps (8.4%).

CONCLUSIONS

Both flaps are valid options in reconstructing pediatric foot and ankle defects. Each flap has advantages and disadvantages as discussed in this review article. In general for larger defects, an ALT flap was used. Flap choice should be based on the size of the defect.

Reconstruction of Extensive Soft Tissue Defects of Lower Extremity With the Extended Anterolateral Thigh Flap

The anterolateral thigh flap is a classic flap used for various reconstruction defects. However, the flap viability of extended large skin paddles (ie, 240 cm²) was doubted by many surgeons. This study reports successful experience of reconstructing extensive soft tissue defects of lower extremity using extended large skin paddles. Twelve consecutive patients who had undergone reconstruction of defects using an extended anterolateral thigh flap were identified. Patient characteristics (age, sex, defect location, injured structures, and type of flap) and outcome data were analyzed retrospectively. One artery and 2 accompanying veins were anastomosed to vascularize each flap. Follow-up periods ranged from 10 to 91 months postoperatively. The average size of the flaps was 268.75 cm² (range = 220-391 cm²). All flaps were perforator flaps with one perforator except that 2 perforators were used in 3 patients. Two patients suffered partial flap necrosis of the distal portion with delayed healing. In conclusion, the extended anterolateral thigh flap is a considerable option for massive defects requiring composite tissue coverage. This flap is advantageous for reconstructing various complex defects in the lower extremities, providing a pliable and vascularized tissue to cover exposed extensive defects including tendons, nerves, and bones.