Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 1613e1620

Clinical experience with a reverse-flowanterolateral thigh perforator flap for thereconstruction of soft-tissue defects of the kneeand proximal lower leg

M. Erol Demirseren a,*, Kamran Efendioglu a, C. Ozerk Demiralp a,Kasim Kilicarslan b, Huseyin Akkaya a

aAtaturk Training and Research Hospital, Department of Plastic, Reconstructive and Aesthetic Surgery, Konutkent-2 SitesiB6-C Block No: 4, 06810 Cayyolu, Ankara, TurkeybAtaturk Training and Research Hospital, Department of Orthopedics and Traumatology, Ankara, Turkey

Received 18 March 2011; accepted 29 June 2011

KEYWORDSSoft-tissuereconstruction;Knee;Reverse-flowanterolateral thighperforator flap

* Corresponding author. Tel.: þ90 31E-mail address: medemirseren@ya

1748-6815/$-seefrontmatterª2011Bridoi:10.1016/j.bjps.2011.06.047

Summary Background: Soft-tissue defects in the knee region are usually complex andrequire adequate reconstruction with flaps. The aim of this article is to present the authors’experience using the reverse-flow anterolateral thigh perforator flap for the reconstructionof a variety of soft-tissue defects around the knee including the upper third of the leg.Methods: A total of 17 reverse-flow anterolateral thigh perforator flaps were used for recon-struction of soft-tissue defects around the knee and the upper third of the leg betweenDecember 2006 and December 2010. The ages of patients ranged from 26 to 82 years (mean,64.3). Defect sizes ranged from 6 � 8 to 10 � 14 cm. The application of the reverse-flow ante-rolateral thigh perforator flaps in relation to the variable arterial anatomy was described.Results: The dimensions of the largest flap used for reconstruction were 10 � 16 cm. Theperforators were musculocutaneous in 14 patients and septocutaneous in three patients.The maximal pedicle length was 28 cm. All of the flaps survived. Only two flaps developedpartial skin necrosis at the distal end. Good aesthetic and functional results with adequaterange of motion were achieved in all cases.Conclusion: Despite a variable vascular anatomy that can be challenging for the surgeon,reverse-flow anterolateral thigh perforator flap is a safe and reliable method for reconstruc-tion of the defects around the knee and even the upper third of the leg.ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

2 2420133; fax: þ90 312 2912705.hoo.com (M.E. Demirseren).

tishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

1614 M.E. Demirseren et al.

Introduction Surgical procedure

Reconstruction of skin and soft-tissue defects around theknee joint is often challenging for plastic and orthopaedicsurgeons. The complexity of the problem can be com-pounded by the presence of infection, exposed bone ortendon, an open joint or the presence of a metal fixationdevice or prosthesis.1 The goal of soft-tissue reconstruc-tion around the knee joint is to provide functional andaesthetically acceptable appearance. Successful manage-ment of a patient’s wound includes meticulous debride-ment, planning and execution of a reasonable operativeprocedure. A well-vascularised tissue is necessary toensure wound healing and to facilitate any concomitantorthopaedic procedure.2 Various alternatives for thisdifficult situation, including local cutaneous flaps, fas-ciocutaneous flaps, muscle flaps or free flaps have beendescribed in the literature. Outlining a reconstructive planrequires consideration of the simplest technique likely toachieve wound closure with minimal donor-site morbid-ity.3e5 If a soft-tissue defect around the knee requires flapcoverage, reverse-flow anterolateral thigh (ALT) perfo-rator flap can be a reliable, effective and durable option.This was first introduced in four cases by Zhang.6 In thepresent article, our clinical experience with the use ofreverse-flow ALT perforator flap for the reconstruction ofsoft-tissue defects around the knee in 17 patients waspresented.

Patients and methods

Between December 2006 and December 2010, 17 patientswith unilateral soft-tissue defects around the kneeunderwent reconstruction with 17 ipsilateral reversed-flowALT perforator flaps. Of these patients, nine were maleand eight were female. Ages ranged from 26 to 82 years(mean, 64.3 years). In 12 of the patients, defects occurredafter the total knee arthroplasty operation, whilefour were due to traffic accidents accompanied byopen tibial fractures. In one patient, the defect occurredafter excision of a skin tumour. Defect sizes ranged from6 � 8 to 10 � 14 cm. Five of the patients were diabetic,whereas 11 had notable cardiovascular diseases, such ashypertension or coronary artery disease. Four of thepatients had a combination of diabetic and cardiovasculardiseases. There were no underlying diseases in fivepatients. Operations were performed under generalanaesthesia in 10 and under spinal anaesthesia in sevenof the patients (Table 1). All of the defectsevaluated preoperatively for wound contamination,foreign material, infection, necrotic tissues and boneloss.

Initial treatment necessarily began with aggressivedebridement of bone and adjacent soft tissues, removingforeign materials and infected, non-viable, fibrotic andgranulation tissues. Bone fixation, if needed, was per-formed by the orthopaedic surgeon in the earlier operativestage. The knees were splinted in the extended position for1 week postoperatively. The follow-up period ranged from 5to 27 months (mean, 11 months).

Preoperative markings were made, as already described inthe literature. The operation started with the longitudinalincision over the medial margin of the flap, down to themuscle. Subfascial dissection was proceeded laterally, foridentification of the perforators travelling within eitherseptum or muscle. The largest perforator was identified,and the location of the flap or the lateral flap margin wasmodified according to the perforator, if needed. Thedescending branch of the lateral circumflex femoral artery(LCFA) was traced cranially up to its origin, and type of theperforator was identified. Then the lateral incision wascompleted, outlining the final dimensions of the flap to beelevated. Dissection was continued down to the descendingbranch, leaving 0.5 cm of muscle tissue around the perfo-rators. We tried to include as many perforators as possibleto the flap (Figure 1). The descending branch was furtherdissected caudally down to the pivot point, which wasestimated during the flap design. We essentially includeda muscle cuff 1e2 cm thick around the pedicle and thenclamped proximally to assess the retrograde flow into theflap. After the observation for the adequate flap circula-tion, the pedicle was ligated proximally just after thebifurcation points in all type I and III pedicles. In a singlecase with type II pedicle, we ligated the major perforatoremerging from the transverse branch of LCFA just before itsentrance to the flap and elevated the flap on multiple minorperforators emerging from the descending branch of LCFA.A skin incision was made between the distal end of the flapand the defect. Subcutaneous dissection was made formingthe skin flaps bilaterally. The elevated flap was transposedto the defect over the dissected area, and the pedicleswere covered by elevated skin flaps and split-thickness skingrafts in all cases but two, where it was possible toapproximate the lax skin edges forming a subcutaneoustunnel without significant pressure on the pedicles (Figures.2 and 3). The donor site was closed primarily in 10 patients.In the other seven, a split-thickness skin graft was used tofacilitate donor-site closure without any tension. Penrosedrains were placed beneath the flaps and active drains wereused at the donor sites.

Results

All patients had perforators in the mid-lateral thigh region,along the line between the anterior superior iliac spine andthe superolateral margin of the patella, detectable byhandheld portable Doppler. In three flaps (17.7%), trueseptocutaneous perforators were found in the spacebetween the rectus and the vastus lateralis muscles. In theother 14 flaps (82.3%), the perforators were musculocuta-neous, running through the vastus lateralis muscle to thefascia and cutaneous tissue. Of the musculocutaneousperforators, 13 were emerging from the descending branchof the LCFA (type I) and only one was from the transversebranch of the LCFA (type II). All of the septocutaneousperforators were emerging from the descending branch ofLCFA (type III). We did not encounter any septocutaneousperforators emerging from the transverse branch of the LCFA(type IV). Each flap had at least two perforators. The

Table 1 Summary of clinical details.

No Age Gender Aetiology Localisation Defectsize (cm)

Prosthesis Donor-siteclosure

Comorbidity Smoking Medication Anaesthesia Complication

1 72 F After total kneearthroplasty

Right knee 6 � 8 þ Primary HT e Antihypertensive Spinal None

2 26 M Open tibialfracture

Left upper thirdof the tibia

9 � 13 e STSG None 10 package/year

None Generally None

3 71 F After total kneearthroplasty

Right knee 10 � 14 þ Primary HT, DM e Antihypertensive Spinal Distal necrosisin a small area

4 72 F After total kneearthroplasty

Left knee 7 � 10 þ Primary HT e Antihypertensive Generally None

5 37 M Open tibialfracture

Left upper thirdof the tibia

7 � 11 e STSG None 15 package/year

None Spinal None

6 61 M After total kneearthroplasty

Left knee 6 � 10 þ Primary HT, DM,CVR

e Antihypertensive,oral antidiabetic

Generally None

7 71 M After total kneearthroplasty

Left knee 7 � 10 þ STSG HT, DM,Parcinson’sDisease

e Antihypertensive,oral antidiabetic

Generally None

8 75 M After total kneearthroplasty

Right knee 7 � 11 e Primary HT, DM,CAD

e Antihypertensive,oral antidiabetic

Generally None

9 50 F Open tibialfracture

Right upper thirdof the tibia

6 � 13 e STSG None e None Generally Distal necrosisin a small area

10 73 M After total kneearthroplasty

Right knee 7 � 11 e STSG HT e Antihypertensive Spinal None

11 82 F After skintumour excision

Left knee 6 � 9 þ Primary HT e Antihypertensive Generally None

12 75 F After total kneearthroplasty

Right knee 8 � 10 þ Primary HT, CAD e Antihypertensive Generally None

13 61 M After total kneearthroplasty

Left knee 7 � 10 þ Primary None 30 package/year

None Spinal None

14 75 M After total kneearthroplasty

Right knee 6 � 9 þ Primary HT, CAD e Antihypertensive Spinal None

15 72 M After total kneearthroplasty

Right knee 6 � 10 þ STSG HT e Antihypertensive Spinal None

16 65 F After total kneearthroplasty

Left knee 6 � 10 þ STSG DM e Oral antidiabetic General None

17 56 F Open tibialfracture

Right knee 6 � 9 e Primary None þ e General None

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1615

Figure 2 (a) Skin defect with necrotic tissue on the right anteriorthe reverse-flow pedicle surrounded by a cuff of muscle, (d) earlresult, (f) late postoperative result with adequate knee flexion.

Figure 1 Perforator artery and concomitant veins are visibleby transillumination.

1616 M.E. Demirseren et al.

dimensions of the flaps ranged from 8 to 16 cm in length andfrom 6 to 10 cm in width. Dimensions of the largest elevatedflap were 10 � 16 cm in our series. The length of the pedicleranged from 13 to 28 cm, which was enough to reach thedefect without tension. The most distal point of the defectwas 14 cm below the knee joint. In three patients, a strip offascia lata was used to reconstruct the patellar tendon.Dimensions of the included fascia ranged from 2 � 4 to3 � 6 cm. Full range of motion was achieved in all of thepatients by the third month postoperatively, owing to theearly rehabilitation programme. All donor-site woundshealed uneventfully within 2 weeks without any signs ofinfection, wound dehiscence, delayed healing or seroma.Fifteen of the flaps survived completely, while only in twopatients’ flaps, venous congestion occurred in the earlypostoperative period and a small area of necrosis developedat the distal end. Necrotic tissues were debrided and theresulting defects were repaired with small local skin-rotation flap in one patient and split-thickness skin graft inthe other patient (Figures 4 and 5). In the follow-up period,

knee region, (b) planning of the flap, (c) elevated flap based ony postoperative result, (e) anterior view of late postoperative

Figure 3 (a) A long lasting pyogenic granuloma on the left anterior knee region, (b) anterior view of late postoperative result.

Clinical experience with a reverse-flow anterolateral thigh perforator flap 1617

good functional and aesthetic results were achieved with noneed for additional procedures, such as debulking (Figure 6).

Discussion

The knee region and proximal half of the lower leg haveinherent characteristics that can make even a small defecta challenge. Soft-tissue defects of this region are usuallyaccompanied by exposed bone or tendon, an open joint ormetal fixation device or prostheses. In addition, any coin-ciding problem, such as an infection or loss of the patellartendon, will further complicate the situation. The maingoal of soft-tissue reconstruction around the knee joint is torestore contour of the knee while preserving the function.7

Various reconstructive choices, either local flaps or freeflaps, have been used for coverage. Local cutaneous flaps,such as advancement flaps or rotation flaps, can be used foronly very small defects around the knee.4,5 Local fas-ciocutaneous flaps, such as the lateral or medial genicularartery island flap, the lateral sural cutaneous artery islandflap and the saphenous flap, are usually associated withsacrificed perforator or sensory disturbance around theknee joint. The use of these local flaps is limited whenextensive soft-tissue defects are present.8 Local muscleflaps including medial or lateral gastrocnemius, soleus,sartorius, vastus medialis and distally based vastus lateralisare too bulky to cover skin defects around the knee and areusually associated with aesthetic and functional deficits.Moreover, the loss of patellar tendon and overlying skin isdifficult to reconstruct with a local flap.4,5,8 When localflaps have failed, are unavailable or cannot provide

Figure 4 (a) Open tibial fracture with soft-tissue defect on the righ

adequate coverage of the defect, free flaps can be used tocover defects around the knee. Although free flaps can beused to cover defects around the knee, the deep position ofthe recipient vessels at this level makes the vascularanastomosis challenging. Postoperative care is also moredifficult in patients who have undergone microsurgicalreconstruction.2,4,5,9 We think that the reverse-flow ALTperforator flap is a valuable alternative for soft-tissuereconstruction around the knee. Gravvanis et al. statedthat the perforator-flap concept revolutionised recon-structive surgery and, nowadays, we are able to replace“like with like” with minimal donor-site morbidity.2 Thereverse-flow ALT perforator flap has many advantagesincluding a long vascular pedicle, a sufficient tissue supply,possible combination with fascia lata for patellar tendonreconstruction and minimal donor-site morbidity withoutsacrificing major neurovascular structures or muscles. Mostimportantly, this technique allows early mobilisation.Patients can return to their normal daily activities in a shorttime.4 We also performed simultaneous patellar-tendonreconstruction with fascia lata in three of the patients.

According to the literature, although the use of theproximally based ALT flaps have been well described withgood results in numerous publications, there are only fewseries regarding the application of reverse-flow ALT flapsaround the knee, limited to the small number of patients(Table 2).2,4e6,8e16 In this article, we present the largestseries regarding use of reverse-flow ALT perforator flapsreported in the literature up to date.

The ALT flap is based on the septocutaneous and mus-culocutaneous perforators derived from the LCF system.4

The reverse-flow ALT flap and its vascular anatomy was

t lower extremity, (b) anterior view of late postoperative result.

Figure 5 (a) Skin defect with necrotic tissue at the right anterior knee region, (b) anterior view of late postoperative result.

1618 M.E. Demirseren et al.

first described by Zhang in 1990 and applied in four cases.According to the first description of vascular anatomy ofthis flap, blood supply is provided through the anastomosisbetween descending branch of LCFA and lateral superiorgenicular artery in a retrograde fashion.6 Although its firstpublication described a constant pedicle, recent anatomicstudies and cadaveric dissections showed that the anatomyof the pedicle is variable. The retrograde vascular pediclehas been clearly defined by Pan et al. According to theircadaveric dissections, the descending branch alwaysconnects with the lateral superior genicular artery or theprofunda femoral artery or both, which was not mentionedby Zhang et al.4 It was reported that the perfusion from thereverse flow in the distal stump of severed arteries wasadequate enough to establish a successful free-flap recon-struction.17 In their study, Pan et al. showed that the meanretrograde perfusion pressures in reverse-flow ALT flaps areadequate for flap survival. In addition, they stated that thevenous drainage supplied by the venae comitantes was alsoadequate, despite the valves.4 Shieh et al. classified theperforator anatomy of the ALT flaps into four types andstated that this anatomy can be critical for safe elevationof a reverse-flow ALT perforator flap.18 Dissection of theperforators in type I and III flaps (originating fromdescending branch of the LCFA) is easier because of theshorter intramuscular and intermuscular course, respec-tively. If the perforator originates directly from the trans-verse branch of the LCFA (as in type II or type IV), thesurgical procedure can be modified from a reverse-flow ALTflap to a free ALT flap or it can also be raised after ligationof the lateral circumflex femoral vessel proximal to the

Figure 6 (a) Open tibial fracture with soft tissue and bone defeoperative result.

bifurcation of the transverse and descending branches.However, in the second option, to preclude the problem ofvenous drainage, the vascular pedicle (the artery and itsvenae comitantes) should be dissected as a group,preserving the communicating and collateral branchesof the venae comitantes as much as possible. Themotor branch of the femoral nerve running medial tothe descending branch of the LCFA should also bepreserved.4,13,19 However, as described in the literature,even though the perforators supplying the flap tend to belocated in the vicinity of the mid-point of the line betweenthe anterior superior iliac spine and the superolateralmargin of the patella, additional perforators could belocated 5e10 cm proximal and distal to the mid-point.5,20

We also encountered a type II perforator in one case. Inthat case, instead of modifications such as ligation of thelateral circumflex femoral vessel proximal to the bifurca-tion of the transverse and descending branches or a freeflap, we isolated and preserved other perforators emergingfrom the descending branch located more caudally andclamped the major perforator emerging from the transversebranch. After we observed adequate circulation, we ligatedand cut the major perforator and elevated the flap safely onthe perforators emerging from the descending branch.

Another important step in flap elevation is the locationof the pivot point.

According to cadaveric dissection, the pivot point of thereverse-flow ALT flap can be planned 3e10 cm proximal tothe lateral superior angle of the patella. It was suggestedthat the terminal portion of the descending branch shouldbe dissected carefully up to 10 cm above the knee in

ct on the left lower extremity, (b) anterior view of late post-

Table 2 List of the series regarding the application of a reverse-flow ALT flaps reported in the literature.

Numberof Cases

Defect Localisation Complication Additional Procedure Reference

4 Knee region None None 6

2 Popliteal fossa Intraoperative arterialinsufficiency in one case

anastomosis of the second perforator 9

3 anterior knee region none Included fascia lata in one case 4

2 Plantar defect (1)Lower third of theleg defect (1)

NoneNecrosis in a small areaof the distal region

Venous anastomosisHealed spontaneously

10

1 Knee joint none none 11

2 Knee joint none none Including fascia lata 12

1 Lateral knee region none A short vein graft was used as a conduitto bypass the obstructing valve betweenthe descending and transverse branchesof the venae comitantes

13

1 Lateral knee region none none 18

1 Knee joint none none 5

4 Knee contracture none none 14

1 Tibial tuberosity none Venous augmentation using by venousanastomosis between the descendingbranch of the lateral circumflex femoralvein and the branch of medialaccessory saphenous vein

2

3 Lateral side ofthe knee (1)Anterior aspectof the knee (2)

Necrosis in a small areaof the distal and proximalmedial margins (1)Necrosis in thedistal margin (1)

Debridement 8

7 Knee region Partial flap necrosis dueto venous insufficiency (2)

Debridement (1)Debridement and skin grafting (1)

15

1 Anterior aspect ofthe knee joint

none none 16

Clinical experience with a reverse-flow anterolateral thigh perforator flap 1619

a clinical setting.4 If a longer pedicle is needed, the pivotpoint can be placed as distal as possible up to 3 cm abovethe knee. In our patients, reverse-flow ALT perforator flapswith pedicles as long as 28 cm were safely transferred. It issafer to transfer the flap with a cuff of the vastus lateralismuscle included around the pedicle. The cuff will protectthe pedicle from shear forces and will contribute to thevenous outflow.

Arterial or venous insufficiency may easily develop in thereverse-flow ALT flap because of compression of the pediclein the subcutaneous tunnel.9 In accordance, we did nottranspose the flaps through the subcutaneous tunnel.Instead, we incised the skin between the distal end of theflap and the defect, and elevated the skin flaps bilaterallyby subcutaneous dissection. After the flap transposition,those skin flaps were used to cover the pedicle partiallywithout tension and were combined with split-thicknessskin grafts in all but two patients. In those two patients,it was possible to approximate the lax skin edges withoutsignificant pressure on the pedicles.

Although it was recommended to use skin grafts if thewidth of the defect at the donor site is >8 cm,9,15,19 webelieve that the laxity of the skin is themost important factorin closure. In our series, especially in females and elderlypatients, the defects up to 10 cmcould be repairedprimarily.

Conclusions

Although there are some critical points, such as planning ofpivot point, inclusion of muscle cuff around the pedicleduring dissection and prevention of the pedicle compres-sion after the transfer, the reverse-flow ALT perforator flapis a good option, both aesthetically and functionally, forthe reconstruction of soft-tissue defects around theknee joint.

Conflict of Interest

None.

Funding

None.

Ethical approval

Approved by Local Ethical Committee.

1620 M.E. Demirseren et al.

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19. Hong JP, Shin HW, Kim JJ, Wei FC, Chung KY. The use ofanterolateral thigh perforator flaps in chronic osteomyelitis ofthe lower extremity. Plast Reconstr Surg 2005;115:142e8.

20. Yu P, Youssef A. Efficacy of the handheld Doppler in preoper-ative identification of the cutaneous perforators in the ante-rolateral thigh flap. Plast Reconstr Surg 2006;118:928e33.discussion 934e5.