Anterolateral thigh adipofascial flap for the restoration of facial contour deformities

ANTEROLATERAL THIGH ADIPOFASCIAL FLAP FOR THERESTORATION OF FACIAL CONTOUR DEFORMITIES

XIAOLEI JIN, M.D., LI TENG, M.D.,* JIAJIE XU, M.D., JIANJIAN LU, M.D., CHAO ZHANG, M.D., BO ZHANG, M.D.,

and ZHENMIN ZHAO, M.D.

From January 2000 to May 2008, 50 patients with facial contour deformities underwent soft tissue augmentation with 51 anterolateral thigh(ALT) adipofascial flaps. Fifty flaps survived with no complications; partial fat necrosis occurred in one flap. Mean follow-up was 16 months.Flaps ranged from 10 3 6 cm to 20 3 12 cm. Perforators were found in 50 flaps, 43 musculocutaneous perforators (84.3%) and 7 septo-cutaneous perforators (13.7%), with a mean of 2.5 perforators per flap. In one flap (2.0%), no perforator was found. In this case, we usedan anteromedial thigh adipofascial flap using the medial branch of the descending branch of lateral circumflex femoral artery as the vascu-lar pedicle. Relatively symmetric facial contour was achieved in 20 cases. In 30 cases, adjunctive procedures including flap debulking, fatinjection, and resuspension were necessary, and 23 patients achieved satisfactory outcomes. We conclude that the ALT adipofascial flapcan be successfully elevated and transplanted for the correction of soft tissue facial defects. This flap can provide tissue to fill largedefects, and posses the qualities of pliability, an excellent blood supply, ease of suspension and fixation, and minimal morbidity at the do-nor site. VVC 2010 Wiley-Liss, Inc. Microsurgery 30:368–375, 2010.

Congenital and acquired diseases such as hemifacial

microsomia, Romberg’s disease, defects secondary to tu-

mor resection, as well as trauma and iatrogenic injury

can lead to facial contour deformities. An ideal live tissue

augmentation material for the repair of facial soft tissue

defects should be malleable so that it can be shaped

according to the defect. Once in position, the augmenta-

tion material must undergo only minimal change in size

and position. The texture of the material should be soft,

and have a feel similar to subcutaneous tissue.1,2 The de-

velopment of microsurgical techniques has provided inno-

vative options for facial contour reconstruction.

Microsurgical flap reconstruction has many advan-

tages over other procedures, such as nonvascularized au-

tologous tissue graft, biomaterials, and pedicle flaps. Non-

vascularized autologous fat transplantation, for example,

requires repeated injection, unpredictable fat absorption

may occur, and it is not suitable for severe defects.3

Unpredictable absorption may also occur after dermis-fat

grafting. Biomaterials carry the risk of extrusion and

other potentially severe complications.4 Pedicle flaps, for

example, pedicled superficial temporal fascia and pla-

tysma flaps, have sufficient blood flow; however, they

can only be used for mild defects because of their small

tissue volumes.5 A free flap offers the advantages of sin-

gle-stage vascularized soft tissue augmentation and

improved long-term functional and morphological results.

Since Song et al. reported the first use of an anterolat-

eral thigh (ALT) flap as a septocutaneous flap in 1984,6

the versatile ALT flap has been widely used in the recon-

struction of various defects of the head and neck7,8 facial

contour, extremities, flank, and perineum. Published

reports indicate that ALT flaps based on the same blood

supply include perforator-based ultrathin skin flaps, de-

epithelialized flaps, myocutaneous vastus lateralis flaps,

flow-through flaps, and extensive chimeric flaps that

include parts of the surrounding muscles and even seg-

ments of the iliac crest.7–10

The free ALT adipofascial flap includes only the sub-

cutaneous fat and fascia, meets the three aforementioned

conditions required for a facial soft tissue augmentation

material, and is derived from an ideal donor site for res-

toration of facial symmetry. The objective of this report

is to present our experience on facial reconstruction with

the ALT adipofasical flap.

PATIENTS AND METHODS

From January 2000 to May 2008, 51 free ALT adipo-

fascial flaps were used for the reconstruction of facial

subcutaneous soft tissue defect in 50 patients. There were

20 male patients and 30 female with a mean age of 26

years (range, 18–45 years). The causes of facial soft tis-

sue defects included unilateral Romberg’s disease (n 532), bilateral Romberg’s disease (n 5 1), hemifacial

microsomia (n 5 7), facial defect after tumor resection

(n 5 5), and facial atrophy after radiotherapy for heman-

gioma (n 5 5). Of the 50 cases, 27 were left-sided

lesions, 22 were right-sides lesions, and 1 case exhibited

a bilateral lesion. The area of soft tissue defect ranged

from 9 3 5 cm to 19 3 11 cm.

Conflict of Interest: None.

Cranio-Maxillo-Facial Surgery Department 2, Plastic Surgery Hospitalof Peking Union Medical College, Chinese Academy of Medical Sciences,Beijing, China

*Correspondence to: Li Teng, M.D., No. 33, Badachu Road, ShijingshanDistrict, Beijing, China, 100144. E-mail: [email protected]

Received 25 April 2009; Accepted 9 November 2009

Published online 4 January 2010 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/micr.20741

VVC 2010 Wiley-Liss, Inc.

Surgical Technique

Preoperatively, we evaluated the fat mass in the thigh

with skinfold measurement, and if the depth of fat was

too thin (<1 cm) and could not fill the facial defect we

did not proceed with an ALT flap. The area of the soft

tissue defect in the face was measured preoperatively in a

standing position, and a template of the exact dimensions

of the facial defect was produced. Next, according to the

methods of Zhou et al.,11 perforators from the descending

branch of the lateral circumflex femoral artery were iden-

tified with a handheld Doppler probe. Relatively stable

and large perforators were located in a circle with a ra-

dius 3 cm at the midpoint of a line between the anterosu-

perior iliac spine and the superolateral aspect of the pa-

tella.12 The size of flap was designed to be 10–20%

greater than the area of the lesion, and the desired size

was marked on the anterolateral thigh (see Fig. 1). The

largest perforator was located in the center of the flap,

and the long axis of the flap positioned parallel to the

thigh.

At the recipient site, a skin incision only long enough

for transplantation of the flap was made at the cervico-

mandibular border, or in front of the ear, and a subcuta-

neous pocket was prepared. The range of dissection

extended into normal tissue 1 cm beyond the defect. If

the defect was large, an accessory incision was made at

the scalp in the temporal area and/or the lower eyelid

margin. Facial vessels and/or superficial temporal vessels

were exposed as required.

At the donor site, we utilized some modifications

from prior techniques for flap elevation. We incised the

lateral margin of the flap to the subfacial plane and dis-

sected the flap in a lateral to medial direction. After all

of the perforators in the flap were identified, proximal

and distal margins of the flap were incised to the deep

fascia to allow for elevation of the flap. The septum

between the vastus lateralis and the rectus femoris was

divided bluntly to expose the main branch of the de-

scending branch of the lateral circumflex femoral artery,

and the location of the perforator extending from the

main trunk was identified. The medial margin of the flap

was incised and the flap was elevated to the lateral side

at the superficial layer of the rectus femoris. Ordinarily,

the largest preserved perforator can provide the entire

blood supply to the flap. However for safety, other perfo-

rators were retained initially, and vascular clips were

applied to these perforators to ensure that there was

enough blood supply to the flap. Once this was estab-

lished, the extra perforators were ligated. If a split-flap

was needed, more than two perforators were preserved. If

a musculocutaneous perforator was identified, then the

perforator was carefully dissected inside the vastus latera-

lis (Fig. 2A). If it was a septocutaneous perforator, then

it was traced directly to the main trunk through the inter-

muscular septum (Fig. 2B). After the perforator was com-

pletely dissociated, the vascular pedicle of the descending

branch of the lateral circumflex femoral artery was

ligated and cut at the distal end. Before pedicle division,

the tissue flap was trimmed by removing some of the fat

tissue according to the depth of the subunit defects of the

face. Drain tubes were placed in the donor site in all

patients before closure.

The trimmed flap was placed in the prepared subcuta-

neous pocket in the face with upward positioning of the

fat tissue (see Fig. 3). A few pull-up sutures were tied

over an external bolus at various intervals around the

flap. In all of the flaps, the fascia was anchored to the

temporal fascia and/or the periosteum of the zygoma and

infraorbital margin with 3-0 prolene sutures through the

temporal and/or the lower eyelid incision to prevent sag-

ging. The edge of the thinned flap was extended and

fixed to the margin of the pocket inside the normal sub-

cutaneous tissue to prevent insufficient correction of the

edge of the lesion after flap contraction. Once the flap

was in position, the vascular pedicles were anastomosed

to the recipient vessels in an end-to-end fashion.

After the procedure, a tracing of the vascular pedicle

was marked on the surface of the facial skin, and a hand-

held Doppler probe was used to monitor flow in the ar-

tery and vein of the vascular pedicle once every day for

the first three postoperative days. In addition, palpation

of the recipient site was performed daily for evidence of

hematoma formation or venous congestion (suggested by

hardness of the tissue). All patients were treated with

dextran 40, 500 ml day21, beginning at the completion of

the vascular anastomosis for five consecutive days to pro-

vide anticoagulation.

Preoperative and postoperative anterior, lateral, and

oblique photos were evaluated by the surgeons and lay-

persons 6 months after surgery. The degree of improve-

ment in facial symmetry was evaluated and scored as

satisfactory, mostly satisfactory, and unsatisfactory. Satis-

factory indicated that the facial contour was relatively

symmetric and no further surgery was needed. Mostly

satisfactory indicated that the facial contour had improved

significantly, but the face was still mildly asymmetric.

An unsatisfactory score indicated that there was still

significant asymmetry in the face, and further surgical

correction was needed.

RESULTS

There were no microsurgical complications, and 50 of

51 flaps survived completely. Partial fat necrosis occurred

in one flap. Yellow liquid was noted to be draining from

the incision, suggesting fat liquefaction. To evaluate the

condition, we made an incision 3 cm in length at the dis-

tal end of the flap, completely removed the necrotic tis-

Anterolateral Thigh Adipofascial Flap 369

Microsurgery DOI 10.1002/micr

sue, and created adequate drainage. Following removal of

the necrotic tissue, a defect remained in half of the area

at the distal end of the transplanted flap. The defect was

successfully repaired with a free dermis-fat graft.

Primary healing of the incision was achieved in 42

donor sites with no skin necrosis or other significant

complications. Seromas occurred in nine donor sites.

Healing of the incision occurred without further compli-

cations after aspiration and application of a compressive

dressing.

In this series, 50 flaps had perforators: 43 were identi-

fied as musculocutaneous perforators (84.3%) and 7 were

septocutaneous perforators (13.7%). In the one flap with-

out a perforator (2.0%), though a vascular signal was

detected by Doppler examination preoperatively, no cor-

responding perforator was found during the operation. In

this case, we dissected to the medial side and used an

anteromedial thigh adipofascial flap using the medial

branch of the descending branch of lateral circumflex

femoral artery as the vascular pedicle. A total of 128 per-

forators with diameters >0.5 mm were dissected. The

number of perforators ranged from 1 to 4 per flap (aver-

age, 2.5 per flap). The mean total operating time was 5.5

hours (range, 4.5–7.5 hours). The mean operative time

for flap dissection with musculocutaneous perforators was

90 min (range, 60–135 min), while the mean for flap dis-

section with septocutaneous perforators was 70 min

(range, 45–110 min). The facial artery and its concomi-

tant vein were utilized as recipient vessels in 46 cases

and superficial temporal artery and its concomitant vein

were utilized as recipient vessels in 4 cases. The area of

the flaps ranged from 10 3 6 cm to 20 3 12 cm. The

mean thickness of the flap was 18.5 mm (range, 10–28

mm). All patients received postoperative follow-up with a

mean follow-up duration of 16 months (range, 6–48

months).

Results of the evaluation of facial contour are pre-

sented in the Table 1. A relatively symmetric facial con-

tour was achieved in 20 of the 50 patients after the

Figure 2. (A) Musculocutaneous perforator flap. (B) Septocutane-

ous perforator flap. [Color figure can be viewed in the online issue,

which is available at www.interscience.wiley.com.]

Figure 3. Trimmed flap placed in the subcutaneous pocket with

upward positioning of fat tissue before wound closure. [Color

figure can be viewed in the online issue, which is available at www.

interscience.wiley.com.]

Figure 1. Representative flap design. [Color figure can be viewed

in the online issue, which is available at www.interscience.wiley.

com.]

370 Jin et al.


primary surgery, and no revision surgery was necessary.

Among the other 30 cases, local bulkiness occurred in 15

cases, and facial liposuction was performed in these

patients. Local insufficient correction occurred at the

edge of the defect in eight cases, and staged autologous

fat injection was carried out. Sagging of the flap occurred

in seven patients, and resuspension of the flap was per-

formed. Conventional treatment methods were used to

correct other deformities of the eyelids, ears, nose, lips,

and bone in 20 cases. For example, defect of the nasal

ala was treated with composite auricular free flaps; ver-

milion defect was repaired with the vermilion flap on the

uninjured side using orbicularis oris muscle as a pedicle

or the contralateral cross-lip flap; bone defect was packed

with autologous bone graft or bone substitutes such as

porous polyethylene; depressed eyelid was treated with

dermis grafting or autologous free granular fat transplan-

tation. Although the thighs were not completely symmet-

ric, patients accepted the condition. No dysfunction of

the knee joint was present in any of the patients.

CASE REPORTS

Case 1

A 21-year-old female was examined with severe

Romberg’s disease affecting the soft tissue and bone on

the left face (Figs. 4A, 4C, and 4E). Contour defect and

mandibular asymmetry were apparent. After performing a

LeFort I osteotomy and a sagittal split osteotomy to cor-

rect the mandibular asymmetry, a free ALT adipofascial

flap (16 3 10 cm) with a musculocutaneous perforator

was transplanted to the left face. The flap survived with-

out any complications. The facial morphology of the

affected side was noted to be significantly improved

2 years after the procedure and the final outcome was

satisfactory (Figs. 4B, 4D, and 4F).

Case 2

A 29-year-old female was examined with bilateral

Romberg’s disease who experienced progressive bilateral

facial atrophy that began when she was 19-years old and

progressed insidiously until she reached age 26, after

which it remained stationary (Fig. 5A). Two free ALT

adipofascial flaps of the same size (15 3 9 cm) were

simultaneously transplanted to the face to correct the

bilateral defects (Fig. 5B). One year after the surgery, lip-

osuction of the facial flaps was performed to thin the

flaps and a completely symmetric facial contour was

achieved (Fig. 5C). The final outcome was considered

satisfactory.

DISCUSSION

Facial concave deformity or contraction, which is

caused by various congenital or acquired diseases, often

results in asymmetry of the facial contour and remains a

Table 1. Patient Outcomes

Number of patients Final outcome

No secondary procedure 20 Satisfactory: 17

Mostly satisfactory: 3

Unsatisfactory: 0

Single secondary procedure Flap debulking 12 Satisfactory: 10


Unsatisfactory: 0

Fat injection 2 Satisfactory: 1


Unsatisfactory: 0

Resuspension 7 Satisfactory: 5


Unsatisfactory: 0

Two secondary procedures Flap debulking 3 Satisfactory: 2

Fat injection Mostly satisfactory: 1

Unsatisfactory: 0

Flap debulking 4 Satisfactory: 3

Resuspension Mostly satisfactory: 1

Unsatisfactory: 0

Fat injection 0

Re-suspension

Three secondary procedures Flap debulking Satisfactory: 2

Fat injection 2 Mostly satisfactory: 0

Re-suspension Unsatisfactory: 0

Total secondary procedures 30 Satisfactory: 23


Unsatisfactory: 0



challenge to plastic surgeons. Soft tissue augmentation

with autologous soft tissue can achieve excellent facial

symmetry in patients with facial concave deformities. For

the past 20 years, free flap transplantation has been the

‘‘gold standard’’ for the correction of facial concave

deformities.13

The choice of free flaps include those from the

groin,14,15 radial forearm,16 scapular,17 parascapular,18 lat-

issimus dorsi,19 transverse rectus abdominis myocutane-

ous (TRAM),20 deep inferior epigastric perforator

(DIEP),21 superficial inferior epigastric,22 and omental

free flaps.23,24 Each flap has its own advantages and dis-

advantages, and no particular flap is considered a univer-

sal choice for treating facial concave deformities.

The radial forearm flap has a stable, large-caliber ves-

sel and a long vascular pedicle, but its area is limited

Figure 4. (A, C, E) Contour defect and mandibular asymmetry are apparent. After correction of the mandibular asymmetry, a free ALT adi-

pofascial flap (16 3 10 cm) was transplanted. (B, D, F) Facial morphology is noted to be significantly improved 2 years after the proce-

dure. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.]

372 Jin et al.


and a large artery has to be sacrificed. Additionally, an

unsightly scar is produced in the forearm.16 Muscle flaps,

such as the serratus, latissimus dorsi, and TRAM, have

long vascular pedicles and can provide sufficient tissue

volume.19,20,25 Although they can be used for extensive

contour defects, they can exhibit unpredictable muscle

contracture postoperatively. Additionally, muscle flaps do

not form a smooth facial contour and produce relatively

serious functional injury of the donor site.2 An omental

free flap has a long and large vascular pedicle, and it can

provide abundant fat tissue for a large defect. However,

the amount of fat tissue in the donor site is unpredictable,

and the abdomen must be opened. Furthermore, sagging

occurs easily with the omental free flap.23,24,26 The groin

flap has the advantages of minor functional injury at the

donor site, small scar, and abundant tissue volume. How-

ever, the major disadvantage of this flap is that primary

defatting can be difficult because the pedicle vessel runs

in a deeper layer from the proximal to distal portion.15,27

Scapular and parascapular flaps are useful alternatives for

facial contour augmentation because they have a long

vascular pedicle with large-caliber vessels, excellent

structural strength, a large amount of subcutaneous fat,

and solid dermis.13,18 However, some patients develop

hypertrophic scars at the donor site. In addition, simulta-

neous elevation is difficult because of the proximity of

the donor site to the face. This can potentially necessitate

a change in position during surgery to obtain the flap.2,10

The ALT adipofascial flap is an alternative form of

the ALT flap. Ji et al.28 preformed facial contour recon-

struction with an ALT flap for six patients with hemifa-

cial microsomia and Wang et al.29 utilized an ALT adi-

pofascial flap for seven patients with hemifacial atrophy;

however, the small numbers in those series could not pro-

vide enough information for general outcomes. Wang

et al.29 harvested the flaps using traditional mediolateral

dissection. We also used this dissection method at first;

however, we found later that lateromedial dissection was

more convenient and it aided in the identification of per-

forating branches. Masaki30 treated a patient with hemifa-

cial atrophy by delivering the ALT adipofascial flap

through a gingivobuccal sulcus incision to the periosteum

of the maxillary and zygomatic bones to prevent sagging

and contracture of the flap, and achieved excellent sym-

metrical facial appearance. This kind of method may be

appropriate for a limited depression in the face; however,

it is not suitable for cases with large defects covering the

majority of the facial and forehead areas.

The ALT adipofascial flap has a number of advantages.

It can be thinned during the primary surgery without

affecting its blood supply. Because the perforating vessel

of the flap flows into the subdermal plexus almost perpen-

dicularly after passing through and perfusing the deep fas-

cia, use of the adipofascial layer alone as a free flap is pos-

sible.31,32 The application of some free flaps without epi-

dermis for facial augmentation often results in the dermis

sticking to the subcutaneous tissue at the recipient site.2,33

The adhesion and fibrosis of the dermis can easily result in

contraction, and prevents the facial skin from becoming

smooth and round.2,33 In the transplanted ALT adipofascial

flap, the fat layer adheres to the subcutaneous tissue to

avoid contraction and produces a relatively smooth facial

morphology, and the fascia adheres to the layer of the su-

perficial musculoaponeurotic system (SMAS), which is

consistent with normal facial anatomy. Additionally, the

thick and tenacious fascia lata can be suspended to the fas-

cia of the temporalis and/or the periosteum of the zygo-

matic bone and infraorbital margin to effectively prevent

flap sagging. In patients with associated defects in the lips,

nasal alar, and nasal dorsum, the pliable fascia can be

packed into the subcutaneous layer to meet the subunit

morphology of the face in that area, and can appear more

Figure 5. (A) Frontal view before surgery. Two free ALT adipofascial flaps of the same size (15 3 9 cm) were simultaneously transplanted.

(B) Frontal view 1 year after surgery. One year after surgery, liposuction was performed to thin the flaps. (C) Frontal view 3 months after

liposuction. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.]



natural than augmentation with fat tissue only. ALT adipo-

fascial flaps with two perforators can be split partially or

totally to produce a split-flap, which is useful for some

types of large defects. Lastly, because the ALT adipofas-

cial flap does not contain skin, primary closure of the do-

nor site is possible and no skin grafting is required. Post-

operative functional injury of the donor site is mild, and

the scar is short and subtle.

Other authors have suggested preserving a small skin

island on the surface of the flap for monitoring purposes.2

We did not employ this technique because the location of

the skin island cannot be identified accurately preopera-

tively, and a larger scar will be left at the donor site.

Furthermore, primary thinning cannot be carried out at

the part of the flap with the skin island, thus leaving an

uneven surface and potentially requiring a secondary sur-

gery for excision of the skin island and thinning the flap.

In the present report, adjunctive procedures such as

liposuction to debulk the flap, fat injection to fill the edge

of the flap, and flap resuspension to correct gravitational

sag were employed if, after first surgical procedure, the

flap became bulky, sagged, or was partially undercor-

rected, and better morphological results were desired. In

the present series, adjunctive procedures were employed in

60% of the cases. Though defatting and debulking can be

carried out during the first procedure, the flap should not

be debulked excessively because of unpredictable flap con-

tracture. Liposuction or open defatting and debulking can

be easily performed during a second procedure; however,

it is difficult to fill excessively debulked tissue. The fat

from liposuction can also be used to fill facial depressions,

and a perfectly symmetric appearance can be achieved.

Flap atrophy and tissue flap contracture occurred in

some patients postoperatively, and autologous fat trans-

plantation was performed for insufficient correction.

Although we applied some measures to avoid the flap

sagging during the primary surgery, for some patients

with bulky flaps gravitational sag was inevitable and a

second surgery was necessary for flap resuspension. For

patients who have sagging, the flap is resuspended to the

fascia temporalis or the zygoma periosteum through a

temporal incision or an inferior orbital margin incision.

In short, a perfectly symmetric appearance can be

achieved by using the aforementioned adjunctive meth-

ods, either solely or jointly to correct the various defects

after the first stage.

The ALT adipofascial flap has some disadvantages. In

the present study, the rate of seroma formation at the do-

nor site was high (9/51, 17.6%), and it caused delayed

healing and disruption of some wounds. In this series, we

believe the high incidence of seroma formation was due

to a large area of muscle adhering to the subcutaneous

tissue after the exposure of the fascia lata, increased exu-

dation of the muscle surface, insufficient postoperative

compressive dressing, and inadequate immobilization of

the donor site postoperatively. The other shortcoming is

the variation in vascular pedicles and difficulty in dissec-

tion of the perforator, which has been described in the

previous literature.34–38

CONCLUSIONS

In summary, the ALT adipofascial flap can be success-

fully elevated and transplanted for the correction of soft tis-

sue facial defects. This flap can provide tissue to fill large

defects, and posses the qualities of pliability, an excellent

blood supply, ease of suspension and fixation, and minimal

morbidity at the donor site. Disadvantages such as the varia-

tion in vascular pedicles and difficulty in dissection of mus-

culocutaneous perforators can be overcome with knowledge

of the vascular anatomy and surgical experience. Though

the ALT adipofascial flap has a certain advantages, further

evaluation and improvement are required since 60% of the

cases in the current series required additional procedures to

achieve a satisfactory outcome.

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Anterolateral thigh adipofascial flap for the restoration of facial contour deformities