LETTER TO THE EDITOR

MICROSURGERY 34:247–248 (2014)

COMMENTS ON: “SPLIT RECTUS ABDOMINIS MYOCUTANEOUSDOUBLE FREE FLAP FOR EXTREMITY RECONSTRUCTION”

Dear Editor

It was with great interest that we read the article entitled

“Split rectus abdominis myocutaneous double free flap

for extremity reconstruction” that was recently published

in “Microsurgery”.1 The authors must be commended on

their efforts, and excellent functional result achieved, fol-

lowing such a devastating bilateral lower limb injury.

Indeed, in many units around the world this sort of injury

may well have led to amputation, chronic osteomyelitis

or at best severe functional impairment, and the fact that

the patient is now ambulating unassisted only 6 months

after the injury is testament to the excellent care he

received at the authors institution.

We would like to bring to the readers’ attention,

however, the excellent versatility of the thigh in provid-

ing double free flaps from a single donor site. We note

that the authors had considered using anterolateral thigh

(ALT) free flaps for reconstruction but had decided

against this on the basis of wanting to avoid two donor

sites. The unilateral rectus was chosen instead as it

can, when split, provide two free flaps from a single

donor site. The authors go on to mention that this is

the first report of a split rectus abdominis free flap for

the reconstruction of bilateral lower limb defects, how-

ever this technique has been well established at our

institution for the reconstruction of both moderate to

large-sized defects at two separate sites in the upper

and lower extremity since 1995.2 Moreover, with the

trend towards the harvest of freestyle perforator flaps,3

and the subsequent preservation of donor site integrity,

came a renewed and creative drive within our unit

towards the use of these freestyle flaps for the coverage

of difficult lower extremity defects. Theoretically any

region in the body can be a donor site for skin flaps

based on available perforators, and in our experience

the thigh provides an excellent source of well vascular-

ized tissue that can be harvested in a number of crea-

tive ways while minimizing donor site morbidity. The

ability to harvest a sizable skin paddle in combination

with multiple tissue components with a long, large cali-

ber pedicle attests to the versatility of such flaps.

Indeed, when tackling bilateral lower limb defects a

large ALT based upon two perforators, one a proximal

perforator of the transverse or descending branch of the

lateral circumflex femoral artery (LCFA), and a second

of the descending branch of the LCFA, can nourish a large

skin flap that can then be split into two separate flaps. The

pedicle to the proximal skin flap is the LCFA, and the

pedicle to the distal flap is the descending branch of the

LCFA. Alternatively, a chimeric flap can be harvested

whereby an ALT based on a proximal perforator is raised

and a segment of vastus lateralis nourished on the distal

run off of the descending branch of the LCFA is also har-

vested. This chimeric flap can then be separated into two

separate flaps, a fasciocutaneous ALT based on the LCFA

and a vastus lateralis muscle flap based on the descending

branch of the LCFA.

Continuing along the theme of freestyle perforator

flaps the antero-medial thigh can also provide an excel-

lent source of soft tissue that is often ignored in lower

limb reconstruction. First reported by Song in 19844 the

antero-medial thigh (AMT) flap is based upon perforators

*Correspondence to: Seng-Feng Jeng, MD, E-Da Hospital, Yida Road,Jiaosu Village, Yanchao District, Kaohsiung 82445, Taiwan.E-mail: jengfamily@hotmail.com

Received 14 October 2013; Revision accepted 18 November 2013;Accepted 6 December 2013

Published online 21 December 2013 in Wiley Online Library(wileyonlinelibrary.com). DOI: 10.1002/micr.22213

� 2013 Wiley Periodicals, Inc.

that can arise from either the superficial femoral artery,

profunda femoris, or from an innominate branch of the

LCFA. In our experience of 41 consecutive AMT flaps

raised to reconstruct defects secondary to recurrent head

and neck cancer, sizable perforators were found in 100%

of cases demonstrating good reliability of the vascular

supply to this area.4 Indeed, each AMT flap in this series

was raised from a thigh in which a previous ALT had

been harvested, and the question of whether harvesting

two perforator flaps from the same thigh might have a

cumulative effect on the donor site morbidity and lead to

muscular weakness in the quadriceps was raised. How-

ever, kinetic tests revealed no differences between the

peak torques of the quadriceps or hamstrings between the

donor and normal legs in our patients.5 Evidently an

ALT flap can be harvested while at the same time safely

harvesting an AMT from the same thigh using the free-

style technique of perforator dissection, without

impacting upon quadriceps function, and also keeping the

donor site confined not only to the same leg but also to

the same thigh. This represents another excellent

reconstructive option that can be used when wanting to

harvest two free flaps from a single donor site, while

avoiding the donor site morbidity associated with the

harvest of a rectus.

In summary, when dealing with severe bilateral

extremity injuries requiring soft tissue reconstruction, we

feel that the thigh provides an excellent source of well

vascularized soft tissue that can be harvested in a number

of creative ways. This can lead to two separate free flaps

being derived from a single thigh whilst maintaining the

functional integrity of the quadriceps.

PARVIZ L. SADIGH, MB ChB

Microsurgical Fellow

SENG-FENG JENG, MD*

Professor of Plastic Surgery

E-Da Hospital

Yida Road

Jiaosu Village

Yanchao District

Kaohsiung 82445

Taiwan

REFERENCES

1. Nayame TT, Holzer PW, Helm DL, Maman DY, Winograd JM,Cetrulo CL. Split rectus abdominis myocutaneous double free flap forextremity reconstruction. Microsurgery 2013;doi:10.1002/micr. [Epubahead of print].

2. Jeng SF, Wei FC, Nordhoff MS. One rectus abdominis muscle fortwo separated soft tissue reconstructions. Plast Reconstr Surg 1995;96:1454–1458.

3. Wei FC, Mardini S. Free style free flaps. Plast Reconstr Surg 2004;114:910–916.

4. Song YG, Chen GZ, Song YL. The free thigh flap: A new free flapconcept based on the septocutaneous artery. Br J Plast Surg 1984;37:149–159.

5. Riva FM, Tan NC, Liu KW, Hsieh CH, Jeng SF. Anteromedial thighperforator free flap: Report of 41 consecutive flaps and donor-sitemorbidity evaluation. J Plast Reconstr Aesthet Surg 2013;66:1405–1414.

248 Letter to the Editor

Microsurgery DOI 10.1002/micr