CROSS-LEG FREE ANTEROLATERAL THIGH PERFORATORFLAP: A CASE REPORT

SAVAS SEREL, M.D.,* BURAK KAYA, M.D., OZERK DEMI:RALP, M.D., and ZEKI CAN, M.D.

The purpose of this report is to introduce the cross-leg anterolateral thigh perforator flap for closure of a defect on the dorsum of the foot,and to show that the anterolateral thigh perforator flap is a safe option for a cross-bridge microvascular anastomosis in defects of the ex-tremity. The free anterolateral thigh perforator flap was used for a patient with an unhealed wound on the dorsum of the foot. The flap wasrevascularized by end-to-side anastomosis between the flap’s artery and the posterior tibial artery of the other leg, since there was noavailable recipient artery on the same leg. After a 4-week neovascularization period, the pedicle was cut. To the best of our knowledge,this is the first report of the use of a free anterolateral thigh perforator flap for a cross-bridge microvascular anastomosis.VVC 2006 Wiley-Liss, Inc. Microsurgery 26:190–192, 2006.

The lower extremity has long been notorious for wound-

healing and as an unreliable source of cutaneous flaps.1

The development of free-tissue transfer by microvascular

anastomosis has made it possible to repair a complex tis-

sue defect in a lower extremity.2 The free anterolateral

thigh flap is becoming one of the most preferred options

for soft-tissue reconstruction.3 The success of the repair

depends on the availability of suitable recipient vessels,

as well as selection of an appropriate donor flap and

expert microsurgical skills. The blood circulation in a

transferred tissue must be reestablished by anastomosing

its pedicle to the recipient vessels. In other words, there

must be vessels available for anastomosis.

Unfortunately, limb injuries are sometimes very seri-

ous and complicated, and there may be damage to the

vessels, resulting in vascular obstruction or inflammatory

degeneration in the vessel walls, making these vessels

unsuitable for use. In such cases, selected vessels in the

other limb can play an effective role in providing a tem-

porary blood supply for the transferred tissue. This tech-

nique is called free-tissue transfer using a ‘‘cross-bridge

microvascular anastomosis’’ or ‘‘cross-leg free flap.’’2,4

Different types of flaps, such as the latissimus dorsi

myocutaneous flap and the medial sural gastrocnemius

muscle perforator free flap, were reported as examples of

cross-leg free flaps in the literature.2,5 However, to the best

of our knowledge, the free anterolateral thigh perforator

flap for the cross-leg free flap was not previously reported

in the literature. We present treatment of an unhealed

wound on the right foot with a cross-leg free anterolateral

thigh perforator flap after debridement of the wound.

CASE REPORT

A 46-year-old man with an unhealed wound on his

right foot was admitted to our clinic. He had a burn injury

2 years earlier, and a split-thickness skin graft was

applied for the defect. An ulcer had developed on the skin

grafted area 8 months earlier (Fig. 1). Incisional biopsy

revealed epithelial hyperplasia with papillomatosis. The

wound was debrided under general anesthesia (Fig. 1).

The wound was covered with warm wet gauzes until

transfer of the flap. Since no great saphenous vein and an-

terior tibial artery were seen in the recipient wound, a

cross-bridge procedure became the only alternative The

posterior tibial vessels of the contralateral leg were pre-

pared as recipient vessels through a vertical skin incision,

and a anterolateral thigh perforator flap was harvested

(Fig. 2). After insertion of the flap into the defect, end-to-

end anastomoses were performed between the concomi-

tant veins and the flap’s veins, and end-to-side anastomo-

ses were performed between the flap’s artery and the pos-

terior tibial artery of the contralateral leg (Fig. 3). The

split-thickness skin graft was applied around the flap’s

vascular pedicle (Fig. 3). Two legs were fixed in a cross-

position, and the knee of the donor limb was in flexion.

Two plaster casts were applied around the knee joints and

fixed with a bar. A part of the transferred tissue was left

uncovered, to facilitate postoperative observation and care.

The donor site was closed primarily. The sutures were

removed on postoperative day 14.

After 4 weeks of neovascularization, the flap’s pedicle

was cut (Fig. 4). The patient was followed for 6 postopera-

tive months. No complications occurred in the recipient and

donor sites during the postoperative period (Fig. 5).

DISCUSSION

Free-tissue transfer by vascular anastomosis is now

used frequently. Usually, only when the involved recipient

vessels are shown to be adequate for anastomosis can

blood circulation be reestablished. In other words, vessels

Department of Plastic, Reconstructive, and Aesthetic Surgery, AnkaraUniversity School of Medicine, Ankara, Turkey

*Correspondence to: Savas Serel, M.D., Department of Plastic, Reconstruc-tive, and Aesthetic Surgery, Ankara University School of Medicine, CebeciHospital, 06590 Dikimevi, Ankara, Turkey. E-mail: savasserel@yahoo.com

Received 5 August 2005; Accepted 6 November 2005

Published online 15 February 2006 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/micr.20224

VVC 2006 Wiley-Liss, Inc.

must be available for the anastomosis in the recipient tis-

sue bed with the conventional technique.

The anterior and posterior tibial arteries are the main

arteries in the leg. When the anterior tibial artery and

the great saphenous vein are not suitable for anastomo-

sis, and the posterior tibial artery and the vein of the

same leg are used as alternative vessels for anastomosis,

blood for the leg will be in short supply. The cross-

bridge microvascular anastomosis has become a routine

microreparative procedure whenever a free-tissue transfer

is indicated in the presence of a suspect vascular pedicle

in the recipient site.1,2,4 The cross-bridge procedure is

safe, both for the transferred tissue and the vascularity of

the donor limb.4

In 1979, Taylor et al. introduced a procedure called

‘‘cross-leg free flap.’’6 Different types of flaps, such as the

latissimus dorsi myocutaneous flap, the medial sural gas-

trocnemius muscle perforator free flap, the soleus muscle

flap, the rectus abdominis flap, the parascapular flap, the

tensor fascia lata myocutaneous flap, and the deep circum-

flex iliac artery flap, were reported as examples of cross-

leg free flaps in the literature.2,5,7–11 However, to the best

of our knowledge, the free anterolateral thigh perforator

flap for a cross-leg free flap was not previously reported

in the literature.

Recently, the anterolateral thigh flap first described by

Song et al.12 has gained popularity in soft-tissue reconstruc-

tion.3 It has some advantages in free-flap surgery, including

a long pedicle with a suitable vessel diameter, the availabil-

ity of different tissues with large amounts of skin, and its

adaptability as a sensate or flow-through flap if necessary.3

The flap can be used for reconstruction of head and neck

defects, and has many additional advantages. The anterolat-

Figure 4. View of flap and pedicle 4 weeks after initial surgery.

Figure 5. View of recipient site (left) and donor site (right) 6 months

after surgery.

Figure 1. Left: View of ulcer that developed on skin-grafted area.

Right: Defect after debridement of ulcer.

Figure 2. Anterolateral thigh perforator flap was harvested (left), af-

ter flap elevation (right).

Figure 3. Left: View of inserted flap and anastomosed vessels.

Right: Flap’s pedicle was grafted.

Cross Anterolateral Thigh Flap 191

Microsurgery DOI 10.1002/micr

eral thigh flap is also appropriate for reconstruction of the

upper and lower extremities and trunk. It is also a good al-

ternative flap for breast reconstruction if lower abdominal-

wall tissue is not available.3,12

CONCLUSIONS

Factors specific to the individual patient must always

be taken into consideration in donor-site selection. With

its many advantages, the free anterolateral thigh perforator

flap can be used safely for many purposes. We believe

that the free anterolateral thigh perforator flap is also a

versatile and a safe option for the cross-leg free-flap pro-

cedure in extremity defects, if there are no suitable ves-

sels for anastomosis in the same leg.

REFERENCES

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192 Serel et al.

Microsurgery DOI 10.1002/micr