British Journal of Plastic Surgery

Anterolateral thigh flap: technical tip to facilitate elevation

Sir, The recent article by Zhou et al. (British Journal of Plastic Surgery, 44, 91) concerning the anterolateral thigh flap has prompted me to offer readers the following technical tip which greatly facilitates the dissection of this excellent flap. Neither Zhou’s article, nor any of the other articles on this flap published in the English literature, have made any reference to the use of a tourniquet on the leg when elevating this flap. The other details of the elevation and anatomy have been otherwise well described and one must conclude that a tourniquet has not been used. The reason may well be that both inflatable and Esmarch tourniquets, when applied in the standard fashion, cannot be positioned high enough to be clear of the operative field. There is also no doubt that the elevation is much simplified by a bloodless field, particularly when the perforators pass through vastus lateralis and require significant amounts of muscle division to free the flap. The solution to this problem lies in the use of a Steinmann pin in conjunction with a sterile Esmarch tourniquet, in a similar manner to that used for isolated limb perfusion. The procedure is illustrated in the figures and the steps are as follows :

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The thigh is prepared and draped so as to include exposure of the anterior superior iliac spine (ASIS). A stab wound is made over the ASIS and a pilot hole drilled. A Steinmann pin is inserted into the bone. The leg is elevated (but not exsanguinated by compres- sion, as some blood in the vessels helps in their identification). A large gauze swab is impaled at one corner on the Steinmann pin and the remainder of the swab stretched out on the thigh. A sterile Esmarch tourniquet is applied around the thigh on top of the gauze swab. The distal end of the swab is then lifted up and by pulling forcefully on it in a cephalic direction, the Esmarch tourniquet is drawn up clear of the operative field. The swab is then impaled over the Steinmann pin. Once the flap has been elevated the tourniquet is no longer necessary and it can then be removed so as to enable the proximal end of the pedicle to be pursued to its limit.

The manoeuvre with the swab and pin also has the effect of flexing the hip slightly, but this not a problem and is well worth it for the improved exposure in the operative field.

Yours faithfully, George Cormack FRCSEd Senior Registrar in Plastic Surgery, The Queen Victoria Hospital, East Grinstead, UK

Reference

Zhou, G., Qiao, Q., Chen, G. Y., J.&g, Y. C. and Swift, R. (1991). Clinical experience and surgical anatomy of 32 free anterolateral thigh flap transplantations. British Journal of Plastic Surgery, 44, 91.

Neonatal cleft lip repair

Sir, The recent paper by Freedlander et al. (British Journal of Plastic Surgery, 43, 197) is a further indication that neo-natal

cleft-lip repair is safe and results in satisfactory repair of the lip deformity. However, they have failed to convince me that it is a truly beneficial and desirable treatment for the majority of clefts.

A number of points need to be considered. From the psychological viewpoint, of course it would seem reasonable to correct a cleft as early as possible; this goes for any congenital abnormality, but is no justification for carrying out the procedure earlier unless it can be shown that the results are just as good as when a conventional timetable is adopted.

Operative details given in the paper are rather scant. There is no mention as to whether the anterior palate and alveolus were also closed and the mention of nasal correction gives the impression that this was given a fairly low priority.

The cleft lip deformity is far more than a lip problem. The nasal deformity is often a lasting stigma which is far more readily noticeable than even a mediocre lip repair. In recent years Anderl, McComb, Salyer and others have reported long-term follow-up of cleft lip repair combined with primary nasal correction and each reports excellent aesthetic results. These authors have set the standard which we must aim to emulate. If it is possible to produce comparable results by operating in the ‘neonatal period then this would be the treatment of choice. This means that surgeons advocating this change in protocol should be able to demonstrate their results, preferably by a controlled trial, before it ,is wise for the majority of us to change our current approach.

Yours faithfuliy, P.M.Gilbert, Dept, ‘of Plastic Surgery, Afd. II/vierde, Sophia Kinderziekenhuis, Gordelweg ‘160, 3038 GE Rotterdam, Netherlands.

References

Anderl, H. (1985). Simultaneous repair of lip and nose in the unilateral cleft (a long-term report). In: Jackson, I. T. and Sommerlad, B. C. (Eds.) Recent Advances in Plastic Surgery. Vol. 3. Edinburgh, Churchill Livingstone, p. 1.

McComb, H..(l985).! Primary cotiection of unilateral cleft lip nasal def&mity:‘a IO-year review. Plastic and Reconstructive Surgery, 75,791.

Salyer,‘K. E. (1986) Primary cosrectioa of the unilateral cleft lip nose: a 15-year experience. P&tic and Reconstructive Surgery, 77, 558.

Neonatal cleft lip I’epair-reply

Sir, There is no good technical reason why surgery to close a cleft lip in the neonatal period should give poorer ‘results. Mr Gilbert is correct in drawing attention to the nasal deformity present in these infants, but until fairlyrecentlyfullcorrective nasal surgery was not the’norm in this country at the time of lip repair. Our series commenced in 1978 and most clefts we reported only had alar base repositioning.

The psychologrcal, benefits of early closure he appears to accept though, as indicated in our paper, no prospective study has’ been published. As anaesthesia ,is safe in experienced hands his objection boils down to’,the’lack of evidence produced for comparable results. Weatherley- White et al. (1987) have already shown this regarding aesthetics.