Super-Thin and Suprafascial Anterolateral Thigh Perforator Flaps for Extremity Reconstruction

Akhil K. Seth; Matthew L. Iorio

doi:10.1055/s-0037-1601422

Journal of Reconstructive Microsurgery, Table of Contents

J Reconstr Microsurg 2017; 33(07): 466-473
DOI: 10.1055/s-0037-1601422

Original Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA

Super-Thin and Suprafascial Anterolateral Thigh Perforator Flaps for Extremity Reconstruction

Akhil K. Seth

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

,

Matthew L. Iorio

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

²Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

› Author Affiliations

Abstract

Background The anterolateral thigh (ALT) flap remains a workhorse for soft tissue reconstruction. However, the traditional ALT flap is often too bulky for resurfacing shallow, distal extremity defects, prohibiting adequate function, or well-fitted orthotics. This study evaluates extremity reconstruction using ALT flaps elevated in the suprafascial or super-thin plane.

Methods Retrospective review of ALT free flap reconstruction from October 2014 to July 2016 was performed. Suprafascial and super-thin flaps were those elevated just above the crural fascia and within the superficial scarpal plane, respectively. Adjunct operative procedures, demographics, and complications were recorded.

Results A total of 25 patients underwent suprafascial (n = 14) or super-thin (n = 11) ALT flap reconstruction for primarily lower extremity wounds (n = 19), with an average age and body mass index of 53.8 years and 26.3 kg/m², respectively. Follow-up was 6.3 months. Comorbidities included smoking (n = 7), diabetes (n = 8), peripheral vascular disease (n = 6), and hypertension (n = 8). The presence of hardware (n = 9), trauma (n = 10), and chronic infection (n = 12) were common risk factors. Average flap size was 8.2 × 21.5 cm, with 64% (n = 16) taken on one perforator. Forty-eight percent (n = 12) were end-to-side anastomoses and 62% (n = 13) utilized one venous anastomosis. Mean hospital stay was 7.8 days with a 24% (n = 6) complication rate. There were no partial or complete flap losses.

Conclusion The ALT flap, elevated in a suprafascial or super-thin plane, is a safe, effective option for extremity soft tissue reconstruction. The decreased flap volume and bulk provides the improved contour and pliability necessary for appropriate distal extremity function. The potential versatility of super-thin flaps reinforces the importance of continued innovation by reconstructive microsurgeons.

Keywords

anterolateral thigh flap - extremity reconstruction - free flap

Full Text

References

References
1 Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984; 37 (02) 149-159
2 Kimata Y, Uchiyama K, Sekido M. , et al. Anterolateral thigh flap for abdominal wall reconstruction. Plast Reconstr Surg 1999; 103 (04) 1191-1197
3 Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993; 92 (03) 421-428 , discussion 429–430
4 Kuo YR, Jeng SF, Kuo MH. , et al. Free anterolateral thigh flap for extremity reconstruction: clinical experience and functional assessment of donor site. Plast Reconstr Surg 2001; 107 (07) 1766-1771
5 Lee YC, Chiu HY, Shieh SJ. The clinical application of anterolateral thigh flap. Plast Surg Int 2011; 2011: 127353
6 Lutz BS, Wei FC. Microsurgical workhorse flaps in head and neck reconstruction. Clin Plast Surg 2005; 32 (03) 421-430 , vii
7 Pribaz JJ, Orgill DP, Epstein MD, Sampson CE, Hergrueter CA. Anterolateral thigh free flap. Ann Plast Surg 1995; 34 (06) 585-592
8 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109 (07) 2219-2226 , discussion 2227–2230
9 Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head Neck 2004; 26 (09) 759-769
10 Ali RS, Bluebond-Langner R, Rodriguez ED, Cheng MH. The versatility of the anterolateral thigh flap. Plast Reconstr Surg 2009; 124 (6, Suppl): e395-e407
11 Dayan JH, Lin CH, Wei FC. The versatility of the anterolateral thigh flap in lower extremity reconstruction. Handchir Mikrochir Plast Chir 2009; 41 (04) 193-202
12 Xie S, Deng X, Chen Y. , et al. Reconstruction of foot and ankle defects with a superthin innervated anterolateral thigh perforator flap. J Plast Surg Hand Surg 2016; 50 (06) 367-374
13 Gedebou TM, Wei FC, Lin CH. Clinical experience of 1,284 free anterolateral thigh flaps. Handchir Mikrochir Plast Chir 2002; 34 (04) 239-244
14 Yang WG, Chiang YC, Wei FC, Feng GM, Chen KT. Thin anterolateral thigh perforator flap using a modified perforator microdissection technique and its clinical application for foot resurfacing. Plast Reconstr Surg 2006; 117 (03) 1004-1008
15 Agostini T, Lazzeri D, Spinelli G. Anterolateral thigh flap thinning: techniques and complications. Ann Plast Surg 2014; 72 (02) 246-252
16 Hong JP, Choi DH, Suh H. , et al. A new plane of elevation: the superficial fascial plane for perforator flap elevation. J Reconstr Microsurg 2014; 30 (07) 491-496
17 Pribaz JJ, Chan RK. Where do perforator flaps fit in our armamentarium?. Clin Plast Surg 2010; 37 (04) 571-579 , xi
18 Ross GL, Dunn R, Kirkpatrick J. , et al. To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects. Br J Plast Surg 2003; 56 (04) 409-413
19 Sharabi SE, Hatef DA, Koshy JC, Jain A, Cole PD, Hollier Jr LH. Is primary thinning of the anterolateral thigh flap recommended?. Ann Plast Surg 2010; 65 (06) 555-559
20 Kimura N, Saitoh M, Hasumi T, Sumiya N, Itoh Y. Clinical application and refinement of the microdissected thin groin flap transfer operation. J Plast Reconstr Aesthet Surg 2009; 62 (11) 1510-1516
21 Cigna E, Minni A, Barbaro M. , et al. An experience on primary thinning and secondary debulking of anterolateral thigh flap in head and neck reconstruction. Eur Rev Med Pharmacol Sci 2012; 16 (08) 1095-1101
22 Chen YC, Scaglioni MF, Carrillo Jimenez LE, Yang JC, Huang EY, Lin TS. Suprafascial anterolateral thigh flap harvest: a better way to minimize donor-site morbidity in head and neck reconstruction. Plast Reconstr Surg 2016; 138 (03) 689-698
23 Hui-Chou HG, Sulek J, Bluebond-Langner R, Rodriguez ED. Secondary refinements of free perforator flaps for lower extremity reconstruction. Plast Reconstr Surg 2011; 127 (01) 248-257
24 Lin TS, Jeng SF, Chiang YC. Resurfacing with full-thickness skin graft after debulking procedure for bulky flap of the hand. J Trauma 2008; 65 (01) 123-126
25 Karastergiou K, Smith SR, Greenberg AS, Fried SK. Sex differences in human adipose tissues - the biology of pear shape. Biol Sex Differ 2012; 3 (01) 13-24
26 Kimura N, Satoh K. Consideration of a thin flap as an entity and clinical applications of the thin anterolateral thigh flap. Plast Reconstr Surg 1996; 97 (05) 985-992